53 





Class _lLb 5,3 
Book t V\5 ^ 
Copyright^ 



COPYRIGHT DEPOSIT. 



DIAGNOSIS BY THE URINE 



MEMMINGER 



DIAGNOSIS BY THE 
URINE 



OR 



THE PRACTICAL EXAMINATION OF URINE WITH 
SPECIAL REFERENCE TO DIAGNOSIS. 



BY 

ALLARD MEMMINGER, M. D., 

PROFESSOR OF CHEMISTRY AND HYGIENE AND CLINICAL PROFESSOR OF 

URINARY DIAGNOSIS IN THE MEDICAL COLLEGE OF THE 

STATE OF SOUTH CAROLINA, 

ETC., ETC. 



THIRD EDITION, ENLARGED AND REVISED 
WITH 27 ILLUSTRATIONS. 



PHILADELPHIA: 

BLAKISTON'S SON & CO. 

1012 WALNUT STREET. 
1908 



<* 



LIBRARY of CONiaftEGSj 
1 wo Copies rteceivof 

jul 11 i*u& 

OLASb & AXCi N< 

COPY tt. 



Copyright, 1908, by P. Blakiston's Son& Co. 



Printed by 

The Maple Press 

York Pa. 



TO 

Students of Medicine and Practitioners at Large 

THIS LITTLE VOLUME IS DEDICATED. 

THE ATTEMPT AT SIMPLICITY OF ARRANGEMENT AND OF STYLE 

IT IS HOPED WILL COMMEND IT TO THEM, AND BE THE 

MEANS OF INCREASING THEIR KNOWLEDGE AND 

DIMINISHING THEIR LABOR IN THIS SPECIAL 

DEPARTMENT OF SCIENCE. 



PREFACE TO THIRD EDITION 



The author, in carefully revising this third edition, 
has added a little more matter, but has kept to the 
original idea of not making the book too bulky. 
Tests have been added here and there which seemed 
to him of service in his work, a reliable and practically 
useful method for the quantitative estimation of 
uric acid, a quantitative method for chlorids, a 
general outline of the anatomy of the kidneys and a 
short method for estimating the permeability of the 
kidneys. 

He has seen, too, nothing since the publishing of the 
second edition to change his views in regard to the 
chapter on the absolutes and relative absolutes of 
solids and urea in urine; far from it, in this edition 
he calls forth caution to those who pass urine under 
the name of renal insufficiency, which is constantly 
free of albumin, but in which the solids and urea are 
as stated in that chapter. He too feels that the views 

vii 



Vlll PREFACE TO THIRD EDITION. 

expressed by him in that edition as to the significance 
of tube-casts have been but verified by his work since. 
He hopes, then, this edition will meet with the 
same favor from his critics as previous editions, and 
that the little volume may continue to be a help to 
students and a safe guide to the busy general practi- 
tioner. 

The Author. 

34 Montague Street, Charleston, South Carolina. 
June, 1908. 



CONTENTS. 

Page. 

Introduction, i 

CHAPTER I. 

Physical Characteristic of Urine in Health, 4 

Amount, 4 

Specific Gravity, 5 

Consistence, 8 

Color, 8 

Transparency and Odor, 9 

Reaction, 9 

CHAPTER II. 
Deviations in the Physical Characteristic of Urine in 

Disease, 10 

Amount, 10 

Specific Gravity, 10 

Color, 12 

Transparency and Odor, 13 

Reaction, 14 

CHAPTER III. 
Deviations in the Normal Chemic Composition of Urine 

in Disease, 17 

Urea, 17 

Estimation of Urea, 18 

Uric Acid, 22 

Estimation of Uric Acid, 25 

Chlorids, 26 

Phosphoric Acid, 30 

ix 



X CONTENTS. 

CHAPTER IV. 

Page. 

Morbid Products in the Urine in Disease, 33 

Albumin, ^ 

Sugar, 3 8 

Composition of Fehling Solution, 43 

CHAPTER V. 

Coloring-matters, 44 

Bile, 44 

Blood, 46 

Bus, 5I 

CHAPTER VI. 

Morbid Products which are Properly Classified as 

Urinary Sediments and Urinary Calculi, ... 56 
Urinary Sediments, 56 

CHAPTER VII. 
Differential Diagnosis of Chronic Bright's Disease, 
Based on a Classification of the Normal Abso- 
lute, the Absolute, and the Relative Absolute 
of Solids and Urea found in Urine with Albumin 

and with or without tube-casts, 60 

Rules for Life Insurance Examiners 85 

CHAPTER VIII. 
Resume, 89 

Diagnosis of Diseases of the Kidney and Urinary Organs, . 89 

Parenchymatous Nephritis, 92 

Chronic Parenchymatous Nephritis, 93 

Interstitial Nephritis, 94 

Pyelitis and Cystitis, 104 

Table for Calculating the Absolute Solid in Urine of 

Specific Gravities Ranging from 1.004 to 1.030, . 109 

Statements of the Results of a Complete Analysis of 

Urine, no 

Index 113 



LIST OF ILLUSTRATIONS. 



Page, 

i. Urinometer, 6 

2. Ureometer of Dr. Doremus, 19 

3. Forms of Uric-acid Crystals, 23 

4. Ruhemann's Uriccmeter 25 

5. Graduated Burette 28 

6. Esbach's Albuminometer, 36 

7. Graduated Burette, 42 

8. Leucin Balls, Tyrosin Sheaves, Double Balls of Ammonium 

Urate, 45 

9. Colored and Colorless Blood-corpuscles of Various Forms, . 47 

10. Shriveled Blood-corpuscles in Urine (Catarrh of the Bladder) 

with Numerous Lymph-corpuscles and Crystals of Triple 

Phosphate, 48 

11. Hemin Crystals, 49 

12. Deposit in Ammoniacal Urine (Alkaline Fermentation), . 50 

13. Acid Ammonium Urate Crystals, 57 

14. Crystals of Cystin, Oxalate of Lime Crystals, 58 

15. Oxalate of Lime Crystals, 59 

16. Coarsely Granular Casts, 61 

17. Acid Sodic Urate in Cylinders, 61 

18. Leukocyte Cast, 61 

19. Blood-cast, 61 

20. Hyaline Casts, 62 

21. Epithelial Cast, 62 

22. Finely Granular Cast, 62 

23. Peculiar Changes of the Red Blood-corpuscles in Hematuria, 62 

24. Crenated Red Blood-corpuscles in Renal Hematuria, ... 63 

25. Deposits in Acid Fermentation of Urine, 64 

26. Apparatus for Determining Freezing Point ot Urine .... 98 

27. Epithelial Cells, 99 



XI 



INTRODUCTION. 



The urine is the secretion of the kidneys, and, nor- 
mally considered, is a solution of tissue which has 
undergone retrograde metamorphosis. The proc- 
ess by which this is brought about is a double one: 
filtration, which occurs chiefly in the Malpighian 
capsules of the kidney, and excretion, which is brought 
about by means of the epithelial lining of the tubules 
of the kidney. Although this is true for all practical 
purposes, still the lines are not so accurately defined 
as this, a certain though small proportion of the ex- 
cretion taking place through the Malpighian tufts, 
and, conversely, a certain percentage of water being 
excreted along with the solids by means of the epithe- 
lium of the tubules. The average composition of 
this fluid is as follows: 



Total solids, 60 

Urea, 30 

Uric acid, 0.5 

Chlorids, 10 

Phosphoric acid, 2.5 

Earthy phosphates, 1 

Sulphuric acid, 1.5 

Hippuric acid, 0.25 

Creatinin, 0.5 



to 65 

35 



gm. 



0.8 
12 
3 

2-5 
o.5 

1 



2 INTRODUCTION. 

In disease the urine, besides showing deviations 
in the normal constituents and physical characteristics, 
contains albumin, sugar, biliary coloring-matter, 
acids and fats, uroerythrin (red coloring-matter), 
ammonium sulphid, blood, leucin and tyrosin, car- 
bonate and oxalate of calcium, carbonate of ammon- 
ium, cystin, xanthin, pus, epithelium, spermatozoa, and 
fungi. 

Kidneys. — The kidneys are two large glandular 
organs located in the upper and posterior walls of the 
abdominal cavity on either side of the spine — the left 
kidney is ordinarily longer than the right and slightly 
narrower than the right. Each kidney is about four 
inches long, two inches wide and one inch thick; they 
weigh about four to five ounces each, the male kidney 
being about two and a half drams heavier than that 
of the female, the left kidney, too, is about six and one- 
half grams more in weight than the right. The kidney 
in form represents the haricot or kidney bean; they 
are situated deep in the loins. The inner border at its 
upper part is about one inch from the middle line of 
the body, the outer border at its lowest part three and 
three-fourths inches from the same line. The upper 
border corresponds with the space between the eleventh 
and twelfth ribs, and the lower with that of middle 
of the third lumbar vertebra. A horizontal line 
then passed through the umbilicus would lie just 
below the lower borders of both kidneys, and a vertical 



INTRODUCTION. 3 

line drawn perpendicularly upward through Poupart's 
ligament to the costal arch would pierce through the 
length of each kidney. The kidneys then rest on the 
crura of the diaphragm, on the anterior lamella of the 
posterior aponeurosis of the transversalis muscle as 
also on the psoas muscle. The right kidney is slightly 
lower than the left, due to the location of the liver, to 
which it touches by its suprarenal capsule. 

The kidneys are surrounded by a thick layer of adi- 
pose tissue, held in the meshes of a loose areolar tissue 
and which constitutes the tunic adiposa. 

The capsule of the kidney is a smooth, closely fitting 
membrane which covers the organs and is attached 
to it by elastic fibers, and adheres by means of connect- 
ive tissue and capillary blood-vessels ; it can be separated 
in the healthy kidney, but in diseased states of the 
organs it brings with it when torn off, small particles 
of kidney substance. The kidney is most liberally sup- 
plied with blood; the renal artery is of large size and 
arises from the aorta slightly below the origin of the 
superior mesenteric artery, the right usually a little 
lower than the left, and both break up then into 
small capillaries each of which abruptly terminate in 
a glomerulus of short capillaries, inclosed in the cap- 
sule of Bowman. The renal vein is short and wide 
and the nerves of the kidney consist of filaments from 
the sympathetic and cerebro-spinal systems. 



Diagnosis by the Urine. 



CHAPTER I. 



PHYSICAL CHARACTERISTICS OF URINE 
IN HEALTH. 

AMOUNT. 

The quantity of urine passed in twenty-four hours 
by one in health is dependent upon so many cir- 
cumstances, at times controlled by mental, emotional, 
and physical causes, that it is hard to give an accurate 
norm. After most careful observations, however, 
extending pver years, the author has arrived at the 
following estimate of quantities as fairly representing, 
in a vast number of cases, a condition of health in the 
adult : 

i. A winter average of 1500 c.c. 

2. A winter occasional average of 2000 c.c, de- 
pending almost entirely on sudden cold changes, ac- 
companied frequently by moist, easterly winds. 

4 



PHYSICAL CHARACTERISTICS IN HEALTH. 5 

3. A winter minimum of 1200 c.c. 

4. A summer average of 1100 c.c. 

5. A summer occasional average of 1500 c.c, 
depending much upon the same conditions as in winter. 

6. A summer minimum of 900 c.c. 

The average quantity, then, of urine passed by one 
in health in the twenty-four hours in winter is 1500 c.c, 
or 50 fluidounces. Most is passed in the afternoon, 
less in the morning, and least at night. Of course, 
the amount passed will be much influenced by the 
causes already mentioned, as also by the quantity of 
fluid taken into the system; but the above is the general 
average for winter in health, and a variation of 500 c.c. 
less than the maximum, or 500 c.c more than the mini- 
mum, must be allowed, not constituting in this varia- 
tion a condition of disease. 

SPECIFIC GRAVITY. 

The specific gravity of normal urine for the twenty- 
four hours has quite an extensive range; and, as in the 
case of quantity, so have our observations shown us 
that quite a different range is to be observed between 
the specific gravity of urine passed in winter and that 
passed in hot weather. 

Winter urine has a general average of 1.018, and 
varies, according to the quantity of water passed, from 
1. 013 to 1.022. 



6 DIAGNOSIS BY THE URINE. 

Summer urine has a general average of 1.023, and 
varies, according to the quantity of water passed, 
from 1. 01 7 to 1.030. 

The urine, too, of children shows very different 




Fig. 1. — Urinometer. 



specific gravities in health and disease from that of 
the adult; and, in the experience of the writer, has a 
normal specific gravity in winter varying from 1.008 
to 1. 012, and in summer, from 1.012 to 1.017. 

The water solids and urea will be found one-third 



PHYSICAL CHARACTERISTICS IN HEALTH. 7 

less than in the adult; therefore calculations made as 
to the normal and relative absolutes of solids and 
urea, as indicating a state of health or disease, must 
be made with this understanding. 

In my experience, also, the urine of old men and 
old women shows a corresponding similarity to that 
of very young persons. 

The specific gravity is most easily obtained by means 
of the urino meter, as follows: 

Fill a small standing glass cylinder four-fifths full 
of the urine, remove all froth by means of filter-paper, 
and place in cylinder the urine float (hydrometer) — 
do not allow the float to touch sides — and read depth 
to which hydrometer sinks; the number so found, if 
the urine has temperature of 6o° to 62 F., represents 
the specific gravity. If the temperature is above or 
below, wait until it becomes 6o° or 62 , and then make 
your observations.* 

From the specific gravity we can approximately, 
and for all usual clinical purposes, calculate the solids 
excreted in the twenty-four hours. The rule is as 
follows: Multiply the decimal of the specific gravity 
by 2.33 and the result will represent the weight of 
solids contained in 1000 c.c. of urine; hence we can, 
if we have the quantity of urine passed in twenty-four 
hours, estimate the weight of solids contained in the 

* Hydrometers carrying temperature-chart on them can be pro- 
cured of Messrs. Eimer & Amend, of New York. 



8 DIAGNOSIS BY THE URINE. 

whole. For example, patient passed 3000 c.c. of urine 
of specific gravity 1.015; therefore 15 X 2.33 = 
34.95 grams of solids contained in 1000 c.c. Conse- 
quently, to arrive at amount in 3000 c.c. we say: 

1000 : 3000 : : 34.95 : x 
x = 104.85 gm. 

If a more accurate determination of the solid matter 
is desired, the same is readily attained by evaporating 
a definite quantity of urine on the water-bath, drying 
at 212 F. the residue thus obtained, and then, by 
means of the chemic balance, ascertaining its weight. 

CONSISTENCE. 

Normal urine is a thin and easily dropping fluid, and 
only becomes viscid when it has undergone or is under- 
going some pathologic change. It foams on being 
shaken, but the same subsides and vanishes very soon 
after; if, however, it contains sugar or albumin, the 
foam remains for a long time. 

COLOR. 

The color of normal urine is a bright amber or 
sherry- wine yellow if the entire quantity for the twenty- 
four hours (1500 c.c.) is taken; if not, the color varies 
in consequence to the time of day taken — on rising in 
the morning it is darker, and during the day, and 
particularly after dinner, the tint is less strong. 



PHYSICIAL CHARACTERISTICS IN HEALTH. 9 

TRANSPARENCY AND ODOR. 

Normal urine is always clear and transparent, and 
shows, on standing, a cloud of mucus; this mucus is 
only mechanically suspended in the urine, and not 
in any wise dissolved; the odor is sharp and slightly 
aromatic, and its cause is at present unknown. 

REACTION. 

The reaction of normal urine for the twenty-four 
hours is slightly acid, the same being caused by the 
presence of acid phosphates of the alkalies. To deter- 
mine whether or not urine is acid, moisten a slip of 
blue litmus-paper with the secretion, and if it changes 
from blue to red, the urine is acid; should the urine 
show an excessive degree of acidity, it is a sign that 
the urine is passing from a normal state to an ab- 
normal one. Having now considered the general 
physical characteristics of normal urine, let us pass on 
to consider a deviation from these and note those 
points which mark the beginning of disease in the 
urinary organs. 



CHAPTER II. 

DEVIATIONS IN THE PHYSICAL CHARACTERISTICS 
OF URINE IN DISEASE. 

AMOUNT. 

As has been previously said, the amount of urine 
passed in health in the twenty-four hours is about 
1500 c.c, or say 50 fluidounces. If the quantity 
is much increased, and habitually so, we have a con- 
dition of things known as polyuria; if, on the other 
hand, it is much diminished, a condition known as 
oliguria; and if entirely suppressed, anuria. 

Polyuria may be either physiologic or pathologic; 
in the first instance it is called urina potus (from 
excessive taking-in of fluids), and in the second hydru- 
ria or diabetes. To make a differential diagnosis 
in these cases, the total quantity of solids passed in 
the twenty-four hours is requisite, so this brings me 
at once to the consideration of the deviations in specific 
gravity which constitute disease. 

SPECIFIC GRAVITY. 

The specific gravity of normal urine, as has been 
said, varies much, being in winter at times 1.013, 

10 



PHYSICAL CHARACTERISTICS IN DISEASE. II 

and again 1.022, but averaging about 1.018. As in 
case, however, of the total quantity of urine passed 
in the twenty-four hours it was shown that an allow- 
ance, excessive or the reverse, to the amount of 500 
c.c. must be made, so in the specific gravity a variation 
of a few degrees either way by itself indicates nothing; 
when, however, a urine habitually falls below the 
winter minimum, or goes above its maximum, it is 
an evidence in the first instance of a pathologic 
hydruria, and in the second of a condition known as 
polyuria. 

This latter condition is commonly called diabetes, 
and is of two kinds: Diabetes insipidus, where the 
solids are all increased, but no sugar is present; when 
sugar is found it is called diabetes mellitus. As 
examples of these different kinds of urine, I will say 
that in the first class of urines— the true pathologic 
hydrurias — we have a urine of low specific gravity, 
1.002 or so, and large quantities of water, 4000 to 
6000 c.c. On calculating the total solids, it will be 
found that they are much diminished, whereas the 
water is in a corresponding degree increased above 
the normal. In the second class of urines the hydrom- 
eter shows a specific gravity of 1.025 to 1.030, and 
the quantity of water is also considerably increased, 
being 1500 c.c. to 2500 c.c. in the twenty-four hours. 
In these urines, if no sugar is found, the increase in 
solids is most surely due to excessive quantity of urea 



12 DIAGNOSIS BY THE URINE. 

or else to phosphoric acid. If the increase of solids 
is due to an increase of phosphates, it is called phos- 
phaturia; when, however, sugar is the cause of the 
increased specific gravity, it is called diabetes mellitus.* 

COLOR. 

Deviations in color mark the beginning of pathologic 
changes going on in the urinary organs. Colorless 
urines of low specific gravity and excessive increase 
of water — 4000 c.c. to 6000 c.c. — evidence a neurotic 
affection. Colorless urines, again, with habitual low 
specific gravity — 1.010 to 1.005 — but not necessarily 
an increase of water, point to atrophy of the kidney 
as the probable cause; as the disease advances, how- 
ever, the water increases beyond the normal. Urines 
also appear dark yellow-red, bright garnet-red, dark 
brown, and greenish yellow. The color in dark 
yellow-red urines is due either to blood or else to a 
coloring-matter called uroerythrin. As the con- 
sideration of the morbid constituents found in urine 
is taken up separately, together with the consideration 
of the other colors named, I will defer this until later 
on, and will consider urines colored garnet-red, as 

* A condition known as chyluria, and simulating phosphatic dia- 
betes, sometimes occurs; the urine here is thick and heavy, and ap- 
pears as a milky white liquid. It coagulates readily on being heated, 
as it contains much fibrin, and the coagulum does not dissolve on the 
addition of acetic acid, as would the phosphates; this reaction, there- 
fore, together with the presence of fat, renders the differential diag- 
nosis in these cases easy. 



PHYSICAL CHARACTERISTICS IN DISEASE. 13 

this color is generally due to foreign vegetable coloring- 
matters. Take three drams of clear urine (filter, if 
not clear) ; add to the same in a test-tube ten drops of 
nitric acid (strong), and boil for a minute; if the red 
is not due to pathologic changes in the urine the color 
will disappear, and on the addition of an alkali it will 
return, to be again dissolved when the urine is once 
more acidified by nitric acid and heated. 

TRANSPARENCY AND ODOR. 

Normal urine being clear and transparent, with 
only floating particles of mucus, a urine deviating 
much from this is an indication of disease in the uri- 
nary organs. To determine this, take a portion of 
the twenty-four hours' urine, place in a glass cylinder, 
and stand same on piece of white paper; by this we 
can determine not only the amount of floating matter 
in the urine, but also, from the same specimen, the 
color, specific gravity, odor, and reaction. If the 
urine by this procedure appears thick and cloudy, 
it may be due simply to an insufficiency of water, or 
else to morbid changes. To differentiate these con- 
ditions, heat the urine in a test-tube, and if all dissolves, 
the turbidity was due to urates; if, on heating, instead 
of clearing up it becomes more turbid, add a few drops 
of acetic acid, and if it now clears up, it is an evi- 
dence that the urine was too concentrated, and there- 
fore the solids precipitated out. 



14 DIAGNOSIS BY THE URINE. 

If, finally, the urine appears with the addition 
of acid and heat as it does without them, the turbidity 
is surely due to bladder or kidney detritus, and may 
therefrom be taken as an indication of disease. 

REACTION. 

Normal human urine shows in the twenty-four 
hours' urine a slightly acid reaction; if, however, the 
urine is taken at different periods of the day, it will 
be found that the acidity varies. Shortly after a 
meal the urine is slightly alkaline, but after a while 
it again rights itself. If the urine shows too decided 
an acid reaction it is abnormal, and marks either an 
excessive quantity of uric acid present or else an acid 
condition of the urine caused by free acid. This 
latter condition is easily determined by taking three 
drams of the twenty- four hours' urine (clear; and, 
if not, filtered so as to make it so), placing it in a 
test-tube, and pouring into it one-half the quantity 
of a strong solution of the hyposulphite of sodium. 
If free acid be present, a turbidity immediately forms 
whose density is in proportion to the quantity of acid 
present. This reaction is caused by the precipitation 
of sulphur, the free acid having united with the sodium 
of the salt. 

The reaction, again, of urine may deviate in the 
opposite direction, constituting an alkaline urine, 
and therefore indicating disease. There are two 



PHYSICAL CHARACTERISTICS IN DISEASE. 1 5 

ways in which the urine may become alkaline, and 
it is very important, from a clinical standpoint, to 
name and understand them. The first is from fixed 
alkali and the second from volatile (carbonate of 
ammonia). 

Both forms of alkaline urine change red litmus- 
paper to blue on being moistened; but in the case of 
fixed alkali, litmus-paper, on being dried, does not 
regain its red color, whereas in the case of urine 
rendered alkaline from volatile alkali, the red litmus- 
paper regains its color on being dried. Urine showing 
the presence of volatile alkali is always an evidence 
of disease (inflammation) of some part of the genito- 
urinary apparatus. 

If there be both fixed and volatile alkali present 
in the urine, the above test will give a negative result; 
so important, however, is it for us to know whether 
or not volatile alkali is present, and therefore if in- 
flammation is to be excluded, that we proceed as 
follows: Place ioo c.c. of the urine in a glass flask, 
to which is fitted a cork; on inserting the cork, allow 
a slip of moistened red litmus-paper to be placed 
against its side and extending dow r n into the flask, 
but not reaching into the urine; heat the flask gently 
(do not boil), and if any carbonate of ammonia is 
present, the red litmus-paper will immediately turn 
blue. I suppose it is needless for me to caution that 
this testmust always be applied to fresh urine. 



1 6 DIAGNOSIS BY THE URINE. 

Urines alkaline from fixed alkali generally effer- 
vesce on the addition of an acid, and though not 
indicating any particular derangement of the kidneys, 
are usually met with in enfeebled conditions of the 
body in which the respiratory act is performed with 
difficulty, and thus carbonic acid is allowed to accu- 
mulate in the system; also whenever the bile is dimin- 
ished, or when there is a tendency to fermentative 
changes in the stomach or intestines. The dyspepsia 
which accompanies this kind of urine is attended 
with great depression of spirit; flatulence is marked, 
the bowels confined, and the skin dark and sallow, 
showing evident derangement of the liver. 



CHAPTER III. 

DEVIATIONS IN THE NORMAL CHEMIC COMPO- 
SITION OF URINE IN DISEASE. 

UREA. 

From a clinical standpoint, of all the normal con- 
stituents found in human urine we need only consider 
urea, uric acid, chlorids, and phosphates of the 
alkalies and alkaline earths. Urea is the main solid 
which is passed in the urine, and averages from 
thirty to thirty-five grams (460 to 540 grs.) in the 
twenty-four hours. It is a diureid, and has the 
formula CON 2 H 4 . 

The quantity of urea excreted from the body in 
the twenty-four hours is much influenced by: (1) The 
amount of nitrogenous food supplied the system; 
(2) amount of active exercise taken during the day; 
and (3) the quantity of water drunk. If the three 
indications are all met, then urea increases very much 
in the urine. If, however, the amount increases and 
the three conditions mentioned are not given, why 
then the increase is an approximate evidence of the 
waste of the system. This takes place in all fevers 
and wasting diseases, and as long as the liver and 

17 



1 8 DIAGNOSIS BY THE URINE. 

kidneys remain intact, the former to manufacture 
and the latter to convey away retrograde tissue prod- 
ucts, why then the estimate from day to day of the 
urea in the urine will be a pretty fair approximate 
estimate of the w r earing away of tissue, and conse- 
quently of the loss of vital force. When urea under 
the before mentioned conditions instead of being 
increased, is found to have decreased, it is then an 
evidence of either a diseased condition of the liver 
or kidneys. It is surprising to see, however, how low 
the urea finally runs in some cases before the fatal 
hour arrives. I have notes of a case treated for two 
months, and on no occasion during this time was 
there more passed than 13.52 grams in the twenty- 
four hours. We can safely say, therefore, that when 
urea in the urine of the twenty-four hours habitually 
falls below twenty grams in the case of an adult of 
active pursuits and well-nourished body, we should 
suspect disease of the liver or else of the kidneys. 

ESTIMATION OF UREA. 

The manner in which the estimation of urea is 
made is very simple and sufficiently accurate for 
clinical purposes. It is founded on the decom- 
position of urea by the action of such an agent as the 
hypobromite of soda: 

H 4 CON 2 + 3 NaBrO = N 2 + C0 2 + 2H 2 + 3 NaBr. 

The results would be a little low if urine contained 



ABNORMAL CHEMIC COMPOSITION IN DISEASE. 19 

urea alone, but since we find in it also uric acid, urates, 
and kreatinin, these, in giving up their nitrogen, 
make up for the loss, and thus nicely counterbalance 
this source of error. The manipulation of the process 
is as follows: We advise for use the most excellent 




Fig. 2. — Ureometer of Dr. Doremus. 



ureometer designed by Dr. Charles Doremus, of 
New York, to whom, allow me to say, the profession 
owes a debt of gratitude for making so simple a proc- 
ess which has heretofore been so the reverse. These 
ureo meters are graduated according to the French 
and English systems, respectively; the manipulation 



20 DIAGNOSIS BY THE URINE. 

with either is the same, but the calculations being 
different, I deem it best to describe the procedure with 
each. 

i. Make a solution of sodium hydrate, ioo grams 
to 250 c.c. of distilled water. Keep this in bottle 
with rubber stopper. 

2. Make solution of hypobromite by adding one 
c.c. of bromin to ten c.c. of sodium hydrate solution 
and diluting with ten c.c. of distilled water. 

It is convenient, instead of making this solution 
previously (which does not keep long), to pour 
directly into the ureometer the sodium hydrate solu- 
tion until the liquid rises to the mark " =/' which is 
on each ureometer; by means, now, of a little nipple 
pipette, which goes with each set, measure out one 
c.c. of bromin, add this to the hydrate solution, and, 
after the bromin has all gone into solution, dilute by 
pouring in water so as to fill the long arm and bend of 
the ureometer; see, now, that the instrument is full, 
and thoroughly luted at the bend in the arm — which 
is easily attained by tilting and then raising again 
until all air has been expelled — and you have a 
thorough and complete mixture. 

The instrument is now in condition for your test, 
and the remarks made are true for the English as 
well as for the French instrument I am describing. 

Draw up by means of the pipette one c.c. of urine 
to be tested; if the urine contains much albumin, 



ABNORMAL CHEMIC COMPOSITION IN DISEASE. 21 

free it of the same by heating, but not boiling; if the 
quantity, however, is small, disregard it, and pass 
the pipette into the ureometer as far as the bend, and 
compress the rubber on end of pipette, thereby causing 
urine to ascend in hypobromite slowly; on so doing, 
there is great disengagement of gas (carbonic acid 
and nitrogen), and after the disturbance is over and 
several minutes are allowed to elapse, the volume of 
nitrogen may be read, as the column of liquid in the 
ureometer will be depressed just in proportion to the 
quantity of evolved gas, the carbonic acid gas being 
all absorbed by the hydrate of sodium. Each division 
mark on the ureometer indicates o.ooi gram of urea 
in one c.c. of urine. The quantity, therefore, of urea 
voided in the twenty-four hours is ascertained by 
multiplying the result of the test by the number of 
cubic centimeters of urine passed during that period. 
When the English ureometer is used — divided, as 
it is, into grains — the solutions are prepared and 
calculation made as follows: 

i. Make a solution of sodium hydrate, six ounces 
to the pint of distilled water; keep this in a bottle with 
rubber stopper. 

2. Make solution of hypobromite of sodium as 
previously described, and proceed exactly in the same 
way with the urine, etc. 

Each division on this ureometer indicates one grain 
of urea in one fluidounce of urine; the quantity, 



22 DIAGNOSIS BY THE URINE. 

therefore, of urea voided in the twenty-four hours is 
ascertained by multiplying the result of the test by 
the number of ounces of urine passed during that 
period. 

URIC ACID. 

Uric acid is found only in small quantity in human 
urine, and when occurring in excessive amounts, its 
great insolubility in w r ater causes it at once to crystal- 
lize out. This, unfortunately, frequently takes place 
in the kidneys, and thus concretions are lodged there 
which form foci of irritation, and finally, if allowed to 
continue, eventuate in one or other of the chronic 
forms of nephritis. 

Uric acid, also in union with sodium, potassium, 
and calcium, is often found in large quantities in 
urine, principally, we may say, in the beginning of 
fevers and in all conditions in which the system is 
subjected either to a higher temperature for a short 
time, or else to a lower temperature for a longer period. 
Along with these urates is precipitated a coloring- 
matter, called uroerythrin; this coloring-matter is 
red, and gives to uric acid and urate deposits a rosy- 
red tint — the so-called brick-dust deposit, so often 
observed in^the pot de chambre in the morning. If 
this deposit habitually occurs in the urine of persons 
not suffering from fever, it is a sign that the liver 
is at fault, and that the gouty or rheumatic gout 



ABNORMAL CHEMIC COMPOSITION IN DISEASE. 23 

diathesis is being established. The presence of 
uroerythrin, uric acid, and urates is most easily ascer- 
tained. 

If these are present, the urine will be turbid, the 




Fig. 3. — Forms of Uric-acid Crystals. 

1. Rhombic plates. 2. Whetstone forms. 3. Quadrate forms. 4,5, 
Prolonged into points. 6, 8. Rosettes. 7. Pointed bundles. 
9. Barrel forms precipitated by added hydrochloric acid to 



urates will clear up on being heated, and the uric 
acid will be dissolved if to the sediment is added 
an alkali. To determine the presence of uroerythrin, 
take three drams of urine, place in a test-tube, add 



24 DIAGNOSIS BY THE URINE. 

one to three drops of a solution of the acetate of lead, 
and if it is present, a precipitate of a rosy pink (flesh 
colored) will immediately fall. When uric acid 
occurs in abnormal amounts, it will be found, if the 
case is one of true lithe mia, that all the other solids 
are diminished; this state of things points strongly 
to grave diseases of the liver, acute yellow atrophy, 
cirrhosis, and cancer. If the urine for the tw r enty- 
four hours is near the normal amount, and uric acid 
crystallizes out a short time after standing, it is in 
abnormal quantity. Its detection is readily made 
in the following manner: Filter, if the urine is not 
clear, ioo ex.; acidify with ten c.c. of strong hydro- 
chloric acid, allow it to stand, and after twelve hours 
uric acid will be found crystallized, and can be verified 
by either the microscope or else by the murexid test, 
which is performed as follows: Take a few of the 
crystals; place on a watch-glass, add a few drops 
of nitric acid, and apply heat gently; after thus attain- 
ing solution of the uric acid, dry carefully over the 
flame, and to the dry and cool mass add a few drops 
of ammonia; if the crystals be uric acid, a most 
magnificent purple color will rapidly spread over the 
touched mass. 



ABNORMAL CHEMIC COMPOSITION IN DISEASE. 25 



ESTIMATION OF URIC ACID, 

BY RUHEMANN'S IODINE 

METHOD. 

This process has been somewhat 
criticized in regard to its absolute ac- 
curacy, but we may add, it gives at 
times absolutely accurate results and 
at all times quite near enough the truth 
when linked with the ease of execution, 
to make it, in our opinion, of great 
service to the clinician. Ruhemann's 
uricometer is to be recommended and 
his reagent solution consists of iodine 
1.5 grams, potassium iodid 1.5 grams, 
and 15 grams of absolute alcohol in 
185 c.c. of water. 

Carbon bisulphid is made to fill the 
instrument to the first line marked S, 
and on this is placed by means of a 
pipette the reagent solution until it 
stands on the next mark, I, on the 
instrument. The urine, now brought 
to the temperature of 65 Fahrenheit, 
is run in by pipette until it stands at 
the lower part of the graduated scale 
marked 2.45. The open end of the 
uricometer is now closed by the glass 



eem 1 

12. oi 

11.8 

11.6 

11.4 

11.2 

11 

10.8 

10.6 

10.4 

10.2 

10.0 



0.175 
0.178 
0.181 
0.184 
0.187 
0.190 
0.193 
0.196 
0.199 
0.202 
0.205 
0208 
0.211 
0.215 
0.218 
0.221 
■ 0.225 
0.228 
0.231 
0.235 
0.238 
0.242 
0.245 
0249 
0.252 
0.26 
0.28 
.0.3 
•0.33 
■0.35 

• 0.38 
■0.41 

• 0.44 
'0.47 



■0653 
•071 
•0.76 




Fig. 4. Ruhe- 
mann's Uricometer. 
(From Lenhartz). 



26 DIAGNOSIS BY THE URINE. 

stopper and the tube vigorously shaken. The carbon 
bisulphid assumes a dark brown color, the stopper is 
removed and more urine added and the process of 
shaking repeated in same way until just enough urine 
is added to make the carbon bisulphid become a pure 
white. 

Read now the scale from the surface of the liquid 
in the tube and the graduations will show at once the 
amount of uric acid in grams per every iooo c.c. of 
urine. 

If albumin, pus or blood be present they must be 
removed by heat, and if the urine is alkaline it must 
first be made slightly acid with acetic acid. Should 
also the urine contain less uric acid than the instru- 
ment is gauged for, add the reagent iodine solution 
to the line half way between I and S and read, dividing 
values by 2. 

CHLORIDS. 

In the urine of adults the chlorids consist almost 
entirely of chlorid of sodium, and the average quantity 
passed in twenty-four hours is between twelve and 
thirteen grams; consequently it ranks next to urea 
as the principal constituent in urine. The quantity 
of chlorids present is subject, as with the other con- 
stituents, to fluctuations; when, however, the average 
falls much below the figures just given, it is a sign 
of disease of the kidneys, or else of the final stage of 



ABNORMAL CHEMIC COMPOSITION IN DISEASE. 27 

some lung trouble or continued fever. Whenever, in 
pneumonia, the chlorids leave the urine, the case 
must be regarded as very serious. In cases of chronic 
nephritis the regular and habitual falling-off of 
chlorid of sodium in the urine gives to the case a 
serious and grave aspect. The chlorids are not 
increased in pathologic urines, but are sometimes 
found in larger quantities than usual when a salt 
diet is instituted. 

To determine whether they are in normal or dimin- 
ished quantity, take two ounces of urine, filter if not 
perfectly clear, and if albumin is present heat with 
nitric acid and filter. Take the filtrate in this case, 
or, if albumin is not present, the clear urine, and 
acidify with nitric acid; add to it four drops of a 
solution of nitrate of silver — strength one part Ag- 
N0 3 to eight parts H 2 — and if chlorids are in 
normal quantity ( \ of one to one per cent.) thick 
curdy masses of chlorid of silver (AgCl) immediately 
fall to the bottom of the test-glass. If, on the other 
hand, the urine contains a small quantity of chlorid — 
say \ to t X q of one per cent. — the solution (urine, etc), 
after the addition of the silver nitrate, shows only a 
cloud, arid instead of the thick masses falling to the 
bottom, which do not mix readily with the urine, we 
have a solution of milky and turbid appearance. 

The gravimetric determination is made as follows: 
Make a decinormal solution of silver nitrate 



28 DIAGNOSIS BY THE URINE. 




Fig. 5. — Graduated Burette. 



ABNORMAL CHEMIC COMPOSITION IN DISEASE. 29 

(AgN0 3 ) 17 grams to 1000 c.c. distilled water. One 
c.c. of this solution is equal to 0.00584 grams of 
sodium chlorid (NaCl). 

Measure out 10 c.c. of clear urine free of albumin 
and to it add 70 c.c. of water. If the urine is high 
colored, oxidize it first by evaporating to dryness the 
10 c.c. with a few crystals of permanganate of potas- 
sium in a procelain evaporating dish, heating thor- 
oughly ; take up with a little nitric acid, dilute with water 
and add to it in this case a few drops of a strong 
solution of the bichromate of potassium, or if not 
high colored, directly and titrate drop by drop with 
the decinormal solution of AgN0 3 until the urine 
shows a faint pink color indicating that silver chro- 
mate is being formed. Multiply the number of 
cubic centimeters run from the burette by 0.00584 
and the result will represent the amount of NaCl 
in 10 cubic centimeters of urine. Normal urines 
require about 10 to 14 c.c. to every 10 c.c. of urine. 

Example: Patient passed 1500 c.c. in 24 hours; 
10 c.c. of this urine was titrated with 14 c.c. of AgN0 3 
solution, therefore 0.00584 X 14 = .08176 gram 
NaCl in 10 c.c, therefore .008176 in 1 c.c, which, 
multiplied by 1500 c.c. gives 12.25 grams NaCl. 



3<D DIAGNOSIS BY THE URINE. 



PHOSPHORIC ACID. 

The amount of phosphoric acid passing from the 
system in the course of twenty-four hours is, as we 
have said, 2.5 to 3.0 grams, and is distributed among 
the bases— lime, magnesia, soda, and potassa. Two- 
thirds are in combination with the oxids of the alkalies, 
and the remaining one-third in union with the oxids 
of the alkaline earths. The alkaline phosphates are 
extremely soluble and are never deposited from the 
urine; on the other hand, the earthy phosphates are 
only held in solution by the acid of the urine, and so 
soon as this is changed to a neutral or alkaline state a 
deposition takes place. To approximately determine 
the quantity of phosphoric acid in the urine: esti- 
mate, by rule already given, the total quantity of solids 
in the urine, expressed in grams; then by the hypo- 
bromite method the total quantity of urea, expressed 
also in grams; to this add eighteen grams, and sub- 
tract the same from the total solids, and the quotient 
divided by four will give the approximate quantity of 
phosphoric acid (P 2 5 ) passing from the body. Thus, 
for example, the total quantity of solids found in a 
certain specimen of urine was 89 grams, the quantity 
of urea was found to be 32 grams, hence, 32+18 
= 50, therefore, 89 — 50 = 39, which divided by 4 
gives 9.75 grams as the daily elimination of phos- 



ABNORMAL CHEMIC COMPOSITION IN DISEASE. 31 

phoric acid in this case. This condition is known 
as phosphaturia or phosphatic diabetes, and as much 
as 8, 10, or 12 grams of phosphoric acid pass away 
in the twenty-four hours. Urines of this class re- 
semble closely the urine of diabetes mellitus — high 
specific gravity; usually a normal quantity of water; 
acid reaction, and an excessive or normal quantity 
of urea. Should, then, a urine show these character- 
istics, and the approximate quantitative test for 
phosphates, as just explained, show their excessive 
amount, an accurate gravimetric determination of 
the phosphoric acid should be made. To this end 
measure out 50 c.c. of clear urine; if albumin is 
present, precipitate out by nitric acid and take filtrate. 
Supposing, therefore, we have 50 c.c. of clear urine : 
add to it 50 c.c. of strong sulphuric acid and 100 c.c. 
of water, boil in a beaker for a few minutes and then 
add a teaspoonful of the nitrate of ammonia (in 
crystals); while still hot add a nitric-acid solution of 
molybdate of ammonia, adding this in excess; stir 
well, boil a few minutes, and cast on a tarred (weighed) 
filter-paper. Wash yellow precipitate two or three 
times with molybdate of ammonia solution; dry at 
212 F. in a steam oven, and weigh precipitate and 
paper; deduct weight of latter from former (precipi- 
tate and paper), and the result will give the weight 
of the precipitate of the phospho molybdate of am- 
monia; this multiplied by 3.142 gives the equivalent 



32 DIAGNOSIS BY THE URINE. 

quantity of phosphoric acid, which in our case repre- 
sents the quantity in 50 c.c. of urine. To find, there- 
fore, the quantity passed in the twenty-four hours is 
but a simple calculation; for example: 

Amount of urine passed in the twenty-four hours was 
2000 c.c; 50 c.c. were taken for analysis, and the ab- 
solute quantity of phosphoric acid (P 2 5 ) in the phos- 
phomolybdate of ammonia precipitate was found to 
be 0.25 grams; consequently, to arrive at the quantity 
passed in twenty-four hours we say: 

50 : 0.25 : : 2000 : x 
x= 10.00 grams (P 2 5 ). 

The nitric-acid solution of molybdate of ammonia 
has the following composition: 

Molybdate of ammonia, 10 gm. 

Solution ammonia, specific gravity 960, . . 40 c.c. 

Strong nitric acid, 80 c.c. 

Water, 80 c.c. 

Dissolve the salt in the ammonia by the aid of heat, 
then pour the solution into the nitric acid and water, 
which have been previously mixed together. 



CHAPTER IV. 

MORBID PRODUCTS IN THE URINE IN DISEASE. 

ALBUMIN. 

Albumin, which has an approximate composition 
of oxygen, 22 per cent.; carbon, 53; nitrogen, 16; 
hydrogen, 7; sulphur, 2, when found in the urine 
habitually with a diminished specific gravity, is an 
unfailing evidence of disease. True, we now and then 
meet with albumin in the urine of those in health; even 
here, however, its appearance is only occasional, its 
quantity small, and never attended with habitual 
diminished specific gravity, as is the case in organic 
disease of the kidneys: this consideration, then, of 
the specific gravity becomes, when albumin is present, 
and even when not, an all-important factor in making 
a differential diagnosis. 

The detection of albumin is easily made as follows: 
(a) Tests Without Heat. — No. 1. Acetic Acid 
and Ferrocyanid of Potassium Test. — This test, when 
executed in the manner laid down in this book, 
will be found to be most delicate, accurate, and re- 
liable, and will, when albumin is present, show it and 
it alone. The presence of the ferrocyanid of potassium 

3 33 



34 DIAGNOSIS BY THE URINE. 

prevents the precipitation of mucin with the acetic acid, 
and, again, in the experience of the author, neither 
peptone, albumose, alkaloids, nor urates are at all 
affected by it. 

The test is applied as follows: Three c.c. of acetic 
acid, specific gravity 1.04 to 1.045, * s m ixed with seven 
c.c. of a solution of the ferrocyanid of potassium, 
strength 1: 15. Tw T enty c.c. of clear urine is now placed 
in a test-tube, and to it is added, drop by drop, the 
test solution; on so doing, if albumin be present, an 
opalescence ensues, the density of which will depend 
upon the quantity of albumin present. If large 
quantities be present, the fluid appears milky, with 
frequently a tinge of green. The adding of the ferro- 
cyanid mixture (test solution), however, should be con- 
tinued until the entire ten c.c. is consumed. To bring 
out the reaction more plainly, the tube should be 
everted several times, holding the thumb at the opening 
so as to prevent the escape of fluid. 

No. 2. Saturated Solution of Picric Acid* — Ap- 
plied in following manner: 

Ten c.c. of a saturated solution of picric acid is 
placed in a test-glass or tube, and on it is gently floated 
twenty c.c. of clear urine. If albumin be present, an 
opalescence immediately forms, density of which de- 
pending upon quantity present. To avoid errors of 

* If the urine is neutral or alkaline, make acid with acetic acid be- 
fore adding the picric acid. 



MORBID PRODUCTS IN DISEASE. 35 

mistaking peptones, etc., for albumin, proceed with the 
picric acid, and heat as described under (6), test No. i. 

No. 3. Nitric Acid. — Three c.c. of clear strong 
nitric acid is placed in a test-glass or tube and on it 
gently floated the same quantity of clear urine whose 
specific gravity is not greater than 1.015. If albumin 
be present, an opalescence ensues just where the urine 
comes in contact with the acid, the density of which 
will depend upon the quantity of albumin present. 
Although urates give somewhat the same haze in this 
test the author has noted it is only so when the urines 
are strong and high specific gravity. To determine, 
therefore, more definitely apply the test with heat as 
described under (b) test No. 2. 

No. 4. — The urine is first treated with acetic acid, 
making acid, concentrated salt or sulphate of sodium 
solution is then boiled with it using equal parts; if 
large amounts of albumin and albumose are present 
a precipitate at once appears, otherwise after heating; 
and if albumose is also present it goes into solution 
on being boiled, leaving only the albumin. 

(b) Tests with Heat. — No. 1. Picric Acid. — Place 
twenty c.c. of clear urine in a test-tube, and heat until 
it boils; if albumin be present, it will precipitate out, 
as an excess of phosphates, however, in a urine which 
is neutral or alkaline will do the same; cool down the 
tube by plunging into very cold water (icy cold, if 
possible); add to it, now, slowly, a saturated solution 



36 



DIAGNOSIS BY THE URINE. 



of picric acid, using about ten c.c; boil again, and 
finally plunge the tube once more into cold water, and, 
if a light, medium, or dense opalescence or precipitate 
is formed, it is albumin. 

No. 2. Nitric Acid. — Place twenty c.c. of clear urine 
in a test-tube, and heat until it boils; if albumin be 
present, it will precipitate out, as 
phosphates may in this test behave as 
just described with picric acid ; plunge 
the tube into very cold water and then 
add a few drops of strong nitric acid 
until acid; boil again, and finally cool 
down, as already stated, by plunging 
into very cold water. If albumin be 
present in small or large quantities, 
the urine shows, in the first instance, 
an opalescence, and in the second a 
decided precipitate. 

I may call attention here to what 
I made, several years ago, the sub- 
ject of an article in the " New York 
Medical Journal " that frequently nitric acid, and 
even picric, when applied in the ordinary way, failed 
to detect very small quantities of albumin, but that if 
after boiling the urines in a test-tube it was suddenly 
plunged into cold water, an appreciable show of albu- 
min was seen. This I have, since writing that article, 
found to take place more frequently in interstitial 



Fig. 6. — Esbach's 
Albuminometer. 



MORBID PRODUCTS IN DISEASE. 37 

nephritis than I then thought, and I am now sure that 
many times when in these cases the urine is reported 
as having no albumin, it is due to the cause I have 
here indicated. 

The volumetric determination of albumin is made 
as follows, using one of Esbach's albumino meters* 
Esbach's solution is also to be recommended as the 
precipitant, and is made by taking twenty grams of 
citric acid, ten grams of picric acid, dissolving them 
in 900 c.c. of hot water, and making up to iooo c.c. 

For analysis, fill the albuminometer up to U (mark 
designated on each tube) with urine; then fill to the 
mark R with the test solution, place rubber cork or 
thumb over the top of the tube, and tilt and raise again 
several times (do not shake); close the tube with a 
cork and leave for twelve or eighteen hours. The lines 
graduated on each albuminometer represent the num- 
ber of grams in the iooo c.c. of urine under examina- 
tion, consequently the line to which the precipitate ex- 
tends marks at once the quantity of albumin in iooo 
c.c; for example, precipitate extended to line marked 
3, and patient passed 120c c.c. in twenty-four hours, 

hence: 

iooo : 1200 : : 3 : x 
x=3.6 gm. 

The points necessary to note in the conduction of 
this process are: (1) That the urine to be examined 
is acid; if not, make so with a few drops of acetic acid. 



38 DIAGNOSIS BY THE URINE. 

(2) If great quantities of albumin are present, dilute 
with one or two volumes of water; of course, the dilu- 
tion must be taken into account in making the final 
calculations.* 

SUGAR. 

The presence of very small quantities of sugar in 
the urine constitutes a condition known as glycosuria; 
whereas if large quantities are found it is called dia- 
betes mellitus. The former condition, if habitual, is 
unnatural, and will, if allowed to run on, eventuate in 
the more formidable complaint. These diseased con- 
ditions of the system by no means point to diseases of 
the kidneys or urinary organs, but really to disease of 
the liver, or, rather, perverted action therein. Some- 
times, also, a diet too exclusively saccharine or 
starchy in its character will bring about this condition 
in those susceptible to this malady. The kidney, 
in ridding itself of this morbid product, becomes 
irritated, and this irritation extends down the entire 
canal, and we thus have produced a real polyuria. 
There are three distinct varieties of this disease 
as regards grade and prognosis. In the first class 
we have a urine of high specific gravity — 1.030 or 

* Turbid urines, which are found to filter with difficulty, either 
should be shaken first with chloroform or talc powder, and then fil- 
tered, or else made slightly alkaline with ammonium hydrate and 
then filtered; after either one of these procedures the tests for albumin 
may be applied; seeing, however, that the urine is first made acid 
with acetic acid. 



MORBID PRODUCTS IN DISEASE. 39 

more — large increase of water, and an increase of all 
the other solids. In the second class, a urine of even 
higher specific gravity — 1.030 to 1.060 — no increase, 
but often diminished volume of water, and an increase 
of all the other solids, constituting thus a true baruria. 
In the third class of cases the urine appears about 
normal in quantity, a little high in specific gravity — 
1.025 to 1.030 — and there is a small quantity of sugar. 
In all cases the urine is decidedly acid, and undergoes, 
after standing a short while, putrid (alkaline) decom- 
position; it is also generally turbid, from the detritus 
of the urinary organs brought about by the irritating 
action of sugar on the mucous membranes. 

All forms of this disease are grave, but the first two 
varieties are the most formidable to treat, and nearly 
always in the young eventuate in an early grave. 
The test for sugar in the urine is made and applied as 
follows : 

1. Picric Acid Test. — This affords an extremely 
simple and delicate test for sugar (glucose) in the urine, 
and has the additional advantage of showing at the 
same time if albumin is present; its reaction with 
sugar is also not interfered with by the presence of 
albumin. Take ten c.c. of clear urine, and to it add 
an equal quantity of a saturated aqueous solution of 
picric acid; boil, and, after so doing, while still very 
hot , add a few drops of caustic potash or soda solution, 
making alkaline; if sugar be present, the color changes 



40 DIAGNOSIS BY THE URINE. 

to a deep red mahogany-brown, and is not to be con- 
founded with the bright cherry-red which occurs in any 
urine when treated in this way. 

2. Heller's Test. — Take a test-tube and place 
in it two drams of urine; if albumin is present, first 
rid the urine of it by means of heat; if, also, the color 
of the urine is dark — which, however, is hardly 
ever the case in diabetic urines — first treat the urine 
with a little lead acetate solution, filter the urine thus 
freed of its color and then take, as said, two drams; 
add to this one dram of caustic soda or caustic potash 
solution, and boil; on so doing the earthy phosphates 
precipitate out, and if they are in large quantities they 
must be filtered out; if not, their presence is disre- 
garded. The color of the urine, if sugar be present, 
changes to a lemon-yellow, yellowish-brown, or black- 
ish-brown, according to the quantity of sugar present. 
Add, now, a few drops of nitric acid; the dark color 
vanishes, and in its place the odor of burnt sugar is 
given off. 

3. Nylander's Test. — Take 2 parts of bismuth 
subnitrate, 4 of Rochelle salts and 100 of an eight per 
cent, solution of sodium hydrate. One part of this so- 
lution is added to 8 or 9 parts by volume of the urine 
and the whole boiled for a short time; a grayish 
coloration of the mixture, after a little becoming deep 
black, indicates the presence of sugar, depth or 
faintness of color indicating in a general way the 



MORBID PRODUCTS IN DISEASE. 41 

amount of sugar present. It is well to remember, how- 
ever, that this test is very delicate and shows smaller 
quantities of sugar when the urines are not too con- 
centrated. Senna, antipyrin, rhubarb, salicylic acid, 
chloroform, chloral, camphor, saccharine and ter- 
pentine must not be in the urine, as they reduce. 

4. MoliscWs Test. — Take a ten per cent, solution of 
a-naphthol in pure methyl or ethyl alcohol. Mix 
2 c.c. with 1 c.c. of urine free of albumin if present; 
add excess of sulphuric acid, and if sugar be present 
a deep violet color is produced. Dilute with water. 
A blue precipitate occurs which is found to be soluble 
in ether, alcohol, or caustic potash, giving on so 
doing a yellow solution. This test is very delicate 
and shows no reaction with urea, uric acid, xanthin, 
creatinin, indican or hippuric acid. 

The gravimetric determination of sugar is effected 
by the use of Fehling's solution, and depends for its 
reaction upon the power of glucose to reduce, in alka- 
line solutions, cupric salts to cuprous — viz., the suboxid 
Cu 2 0. If the urine is clear and free from albumin, 
measure out carefully ten c.c; if it is not, get rid of 
the albumin by heat, filter, and then measure care- 
fully ten c.c. To this add 190 c.c. of distilled water, 
and fill a burette with the same. Carefully measure 
out ten c.c. of Fehling's solution, place in a porcelain 
basin, add forty or fifty c.c. of distilled water, and 
apply heat gently. Into this run from the burette, 



42 



DIAGNOSIS BY THE URINE. 






Fig. 7. — Graduated Burette. 



MORBID PRODUCTS IN DISEASE. 43 

carefully, drop by drop, the diluted urine, and on so 
doing the blue solution will become turbid, gradually 
losing its color, and in its place will appear yellow, 
red, and finally a colorless solution. When this is 
attained it is evident that complete reduction has been 
effected; to make sure, however, take a few drops of 
the supernatant fluid from the porcelain basin, place 
in test-tube, and add a few drops of acetic acid 
and then a little ferrocyanid of potassium (solution); 
if no brown coloration ensues, the process is com- 
pleted; if, on the contrary, you get this reaction, 
continue to run in the urine from burette, drop by 
drop, and test until the reaction with the ferrocyanid 
shows no change in color. To calculate result, get 
total quantity of urine passed in twenty-four hours, 
expressed in cubic centimeters; divide this by the 
number of cubic centimeters run from the burette, 
and the quotient will be the amount of sugar excreted 
in twenty-four hours, expressed in grams. 

Composition of Fehling's Solution. 

Cupric sulphate, 34-64 gm. 

Sodium and potassium tartrate, 173 

Sodium hydrate, 60 

Distilled water, to 1000 c.c. 

Ten c.c. of this solution is reduced by 0.05 gram of sugar. 



CHAPTER V. 
COLORING-MATTERS. 

Abnormal coloring-matters appear at times in 
the urine, but, with the single exception of the color- 
ing derived from blood, do not indicate any special 
form of kidney or urinary disease. 

Bile, when found in the urine, indicates hepatic 
and portal congestions, and gives to it a brown or 
greenish-yellow color. Biliary acids with leucin 
and tryrosin indicate organic disease of the liver, 
generally acute yellow atrophy. Bile is detected 
in the following manner: To ten c.c. of urine is 
added three or four c.c. of a solution of caustic potash 
of exact composition — one part of potash to three of 
water; shake, and to the mixture add an excess of 
hydrochloric acid; if bile be present, the urine assumes 
a beautiful emerald-green color. 

RosenbaMs Test jor Bile. — A few cubic centimeters 
of pure nitric acid to which one drop of a five per cent, 
solution of chromic acid is added, is carefully overlaid 
with urine by means of a pipette. At the point of 
contact a play of the following colors is seen; green; 
blue ; violet ; and reddish-yellow ring. Green, however, 

44 



COLORING-MATTER. 



45 



is the only positive reaction since blue and red may 
be produced by indican or urobilin. This test may 
also be applied to the filter-paper of the filtered bile 
urine, when a play of the same colors is seen. 

Biliary acids are seldom found in any appreciable 




Fig. 8. — a, a. Leucin Balls, b, b. Tyrosin Sheaves, c. Double 
Balls of Ammonium Urate. 



quantities, and as their detection is difficult and the 
pathologic processes which cause them to appear are 
the same as those causing the appearance of leucin and 
tyrosin, I will mention the tests for these latter only. 
Fifty c.c. of urine is taken and evaporated to a small 
bulk; if leucin and tyrosin are present, they will crys- 



46 DIAGNOSIS BY THE URINE. 

tallize out, and may be examined under the micro- 
scope, leucin appearing as oily, circular discs floating 
on the water, and tyrosin as long, prismatic needles; 
should the urine contain albumin, it must be first rid 
of this by using as the precipitant a solution of lead 
acetate, which, again, must be eliminated by pass- 
ing sulphuretted hydrogen through it, and the filtrate 
finally from the lead sulphid thus formed is used for 
evaporation. 

BLOOD. 

Blood appears in the urine under various patho- 
logic conditions of the system, but from a clinical 
chemic standpoint we will consider but two conditions 
in which it constitutes disease of the urinary organs: 
First, when blood-globules or corpuscles are found; 
and secondly, when only the coloring-matter is present. 
The first condition is called hematuria and the second 
hematinuria. Blood may either come from the 
kidneys or else from the bladder, and to make a 
differential diagnosis we must consider the reaction, 
blood coagula, specific gravity, and microscopic ap- 
pearance. Hemorrhage from the kidney is generally 
acid; from the bladder alkaline. When this alkalinity 
is due to the presence of carbonate of ammonia, it is 
then quite certain the hemorrhage was from the blad- 
der. Dark brown or red-brown hemorrhages point to 
the kidneys as the diseased organs, whereas bright red 



COLORING-MATTER. 



47 



would indicate the bladder; smoky, also, to dark 
brown urine points to lesions in the kidney. Soft 
clots, fresh and bright, are generally found in kidney 
hemorrhage, whereas hard, yellow, and sometimes 
colorless clots point to the bladder as the source of 




Fig. 9. — Colored and Colorless Blood-corpuscles of 
Various Forms. 

trouble. Again, long and rod-shaped clots indicate 
hemorrhage from the kidney, whereas large and 
irregular masses are most probably from the blad- 
der. In regard to the specific gravity, we gener- 
ally find in kidney hemorrhage a condition of poly- 
uria; in hemorrhage from the bladder, no polyuria. 



4 8 



DIAGNOSIS BY THE URINE. 



Under the microscope, if the hemorrhage be from 
the kidney, we will find blood-tinged kidney epithe- 
lium, and if from the bladder epithelium correspond- 
ing to the same. For the special diseases causing this 
pathologic change in the urine the reader is referred to 




Fig. io. — Shriveled Blood-corpuscles in Urine (Catarrh 
of the bladder) with Numerous Lymph-corpuscles 
and Caystals of Triple Phosphate. 

special works on this subject, as the scope of this 
treatise does not permit of my so doing. The detec- 
tion of blood in urine is determined either by aid of 
the microscope, by which we can identify the corpus- 
cles, or else by the following chemic tests: 



COLORING-MATTER. 49 

Guaiacum Test. — Mix one c.c. of freshly pre- 
pared tincture of guaiacum with the same quan- 
tity of old oil of turpentine or ozonized ether. Take 
two drams of the urine in a test-glass, and pour the 
guaiacum and turpentine upon the urine; if blood be 
present, between the resinous mass which precipitates 
out and the clear turpentine solution a tinge of blue 




Fig. 11. — Hemin Crystals. 

1. Human. 2. Seal. 3. Calf. 4. Pig. 5. Lamb. 
6. Pike. 7. Rabbit. 



will appear, depth of color depending upon quantity of 
blood present; shake up the mass and it will form 
a blue emulsion. Although this test will answer in 
the majority of cases, it is always well to strengthen 
it with the one I will now give, which is scientifically 
accurate but a little more troublesome to execute. 
Hemin Test. — When corpuscles are not found 
4 



5° 



DIAGNOSIS BY THE URINE. 



in the urine, but simply coloring-matter, apply 
this test: Take three drams of the red urine, boil 
with a concentrated solution of caustic potash, and 
take the phosphatic precipitate which comes down 
with the blood-coloring matter (tinged red) ; dry, and 
mix with a few grains of pure chlorid of sodium; 




Fig. 12. — Deposit in Ammoniacal Urine (Alkaline Fermentation). 

a. Acid Ammonium Urate, b. Ammonio-magnesium Phosphate. 
c. Bacterium Ureae. 



place on watch-glass, add to it one or two drops of 
glacial acetic acid, placing in the mixture a strand of 
hair; after some time hemin crystals crystallize out 
on the hair, and may be identified by means of a 
microscope. 



COLORING-MATTER. 5 1 



PUS. 



Pus in the urine is always the sign of inflammation, 
either of the kidneys or else of the bladder and urinary 
tract. Urines containing pus are generally alkaline 
and if recently passed and of high specific gravity 
and alkaline may be justly considered as evidencing 
inflammation of the bladder; when, on the other hand, 
pus is found in an acid urine recently passed and 
of low specific gravity, it is an indication that the 
inflammation is either of the kidneys or else of the 
ureters. Albumin is also found in these cases, 
but in small quantity. Again, if the pus is from 
disease of the bladder, the specific gravity of the 
urine is normal or else a little above normal. Urines 
containing pus in large quantities are thick, stringy, 
and contain much sediment; the sediment may be 
composed of pus alone, or else of urates, epithelium, 
pus, and blood-globules. To differentiate these con- 
ditions, apply tests already given for blood, urates, 
and uric acid; examine epithelium deposit under 
microscope and apply following special test for pus: 
To the sediment add a solid piece of caustic soda or 
caustic potash; it will lose its color and gradually 
become a stringy, vitreous, and cohesive lump if 
the pus is in large quantity; in small quantities, how- 
ever, the mass dissolves up, and leaves a fluid which 
is only stringy and vitreous. 



52 DIAGNOSIS BY THE URINE. 

Urobilin. — Urobilin is best detected when in 
urine by treating, say five c.c., with ammonia hydrate, 
when, if in large quantity, the fluid assumes a greenish 
hue. The phosphates are now filtered from the urine, 
and to the filtrate is added a solution of chlorid of 
zinc, w r hich, if urobilin be present, brings out a rose- 
red color with a greenish iridescence. 

Clinical Significance, — Urobilin is the chief coloring 
agent of normal urine, and exists in it in small quan- 
tity. It is increased in quantity, however, in acute 
septic fevers, to wit: pyemia, pneumonia, and typhoid 
fever, etc.; it is, on the other hand, diminished in all 
hydremic conditions of the blood, most notably in 
chlorosis, anemia, and hysteria. 

Indican. — Indican is found in normal urine in 
mere traces, and when in larger amounts is abnormal, 
and, by some, considered as an evidence of disease 
of the pancreas. 

Its presence is detected by adding to five c.c. of 
clear urine five c.c. of strong c. p. hydrochloric acid, 
to which three drops only of a solution of chlorinated 
soda have been added. The fluid, on this addition, 
if indican be present, changes to a more or less dark 
color, depth of tint being in proportion to the quantity 
of indican present. To make more sure, however, 
agitate the fluid with a little chloroform, w T hich dis- 
solves out the indigo formed by the above reaction 
and settles as a blue layer at the bottom of the liquid. 



COLORING-MATTER. 53 

Acetone. — Acetone occurs sometimes in normal 
urine in traces, but when in large amounts is abnor- 
mal, and constitutes a condition better known as 
acetonuria. Its presence is detected as follows: 
Five c.c. of clear urine is treated with a few drops of a 
freshly prepared solution of the nitroprussid of sodium 
(strength 1:30). Strong ammonia is then added, 
and in a few minutes, if acetone be present, a red 
color is produced, which, on the addition of acetic 
acid, changes to a purple or violet color. If more 
accuracy is required, the urine must be distilled and 
the distillate treated as just described. 

Clinical Significance. — Acetone frequently occurs 
in the urine in pronounced quantity in high fevers; 
also when a highly nitrogenous diet is indulged in, 
and toward the end of diabetes mellius. 

Peptone. — Peptone does not occur in normal 
urine, and its presence by some is considered to be 
due to the disintegration of pus-corpuscles some- 
where in the body. It is found in the urine in many 
acute and specific fevers — in cerebrospinal menin- 
gitis for instance — and may at times indicate whether 
a pleuritic effusion is purulent or not. Its presence 
in urine is detected as follows: If the urine contains 
albumin, this must first be precipitated out by acetic 
acid and ferrocyanid of potassium, and to the filtrate 
must be added a solution of phosphotungstic acid; 
on so doing a cloudiness appears immediately or 



54 DIAGNOSIS BY THE URINE. 

after a while, depending on the amount of peptone 
present. To urine not containing albumin but having 
much color, a solution of the acetate of lead is first 
added; filtration is then effected, and to the colorless 
filtrate, which is now made acid by acetic acid, the 
phosphotungstic acid is added. 

Ehrlich's Diazo Reaction in Typhoid Fever.— 
Although the Widal method of examining blood in 
typhoid fever has recently somewhat eclipsed Ehrlich's 
test, it is well to know how to apply it, since in the 
experience of the writer it has on many occasions 
given him most trustworthy results. The reaction 
depends upon the fact that sulphanilic acid in the 
presence of nitrous acid (HN0 2 ) forms diazosulpho- 
benzol, which, uniting with certain aromatic substances 
occasionally present in urine, forms anilin colors. 

The process requires two solutions, and is con- 
ducted as follows: 

Solution L — Two grams of sulphanilic acid, fifty 
c.c. of strong c. p. hydrochloric acid, and iooo c.c. 
of distilled water. 

Solution II. — One gram of sodium nitrite to 200 
c.c. of distilled water. 

In performing the test, fifty c.c. of Solution I is 
mixed with one c.c. of Solution II, and of this twenty 
c.c. is taken, placed in a test-tube, and to it added 
twenty c.c. of clear urine. Ammonium hydrate is 
now added until strongly ammoniacal, and if the 



COLORING MATTER. 55 

reaction be positive, the solution assumes a beautiful 
carmin-red, which, on shaking, must also appear 
and stay in the foam. 

To understand its clinical significance, and the 
claims set forth by its author, I quote as follows 
from Ehrlich: 

"1. The reaction is most commonly found in 
typhoid fever from the fourth to the seventh day, 
and thereafter, and if the reaction be absent, the 
diagnosis is doubtful. 

a 2. Cases of typhoid fever characterized by faint 
reaction, and occurring only for a short time, may be 
predicted to be of very mild type. 

"3. The reaction is occasionally noted in phthisis 
pulmonalis, but only in cases pursuing a rapid course 
toward a fatal termination. 

"4. The reaction is sometimes, but not often, 
observed in cases of measles, miliary tuberculosis, 
pyemia, scarlet fever, and erysipelas. 

"5. In diseases unaccompanied by fever, as 
chlorosis, hydremia, diabetes, diseases of the brain, 
spinal cord, liver, and kidneys, the reaction is always 
absent." 



CHAPTER VI. 

MORBID PRODUCTS WHICH ARE PROPERLY CLAS- 
SIFIED AS URINARY SEDIMENTS AND 
URINARY CALCULI. 

URINARY SEDIMENTS. 

Organized and unorganized sediments are found 
in the urine; the former, when present, constitute 
disease, the latter only when in abnormal amounts. 
Tube-casts, blood-corpuscles, epithelium cells, and 
spermatozoids are organized; uric acid, urates, phos- 
phates, and oxalates, unorganized. Uric acid is 
generally in lozenge-shaped crystals, urates indis- 
tinctly crystalline, phosphates generally in distinct 
prismatic crystals, and oxalates in small octahedra 
or dumbbells. 

Urinary calculi are usually composed of either uric 
acid and urates of sodium, potassium, and calcium, 
or else of phosphates and oxalates of calcium; xanthin 
and cystin are only occasionally found. To test 
these calculi, pulverize, place a small portion on 
platinum foil, and heat over the Bunsen flame. 

i. If no residue is left, it is either uric acid, am- 

56 



URINARY SEDIMENT AND CALCULI. 57 

monium urate, xanthin, or cystin. To determine 
this, take a small portion, place on watch-glass, add 
a few drops of dilute nitric acid, and heat to dryness; 
add to this a few drops of ammonia, and if mass 
changes to beautiful purple color (murexid test), 
sediment is either uric acid or urate of ammonia; 
if no change of color, the substance is xanthin or 
cystin. To determine this, take the portion of original 
pulverized calculus, and dissolve in nitric acid on 




Fig. 13. — Acid Ammonium Urate Crystals. 

watch-glass; if solution turns yellow on evaporation, 
and leaves a residue insoluble in potassium carbonate, 
the calculus is xanthin; should the solution, however, 
turn brown, and leave a residue soluble in ammonia, 
it is cystin. 

2. If on heating the pulverized calculus on platinum 
foil a residue is left, the calculus is either a urate of 
calcium, or else an oxalate or phosphate of the same. 
To determine this, dissolve the substance in hydro- 
chloric acid (on a watch-glass); if it effervesces, the 



5» 



DIAGNOSIS BY THE URINE. 



calculus is either a urate or oxalate. If the murexid 
test gives a negative result, why then it is an oxalate. 
If on adding hydrochloric acid solution is attained 
without effervescence, the calculus is a phosphate, 
which may be further verified by adding to the solu- 




Fig. 14. — A. Crystals of Cystin. B. Oxalate of Lime Crystals. 



tion a few drops of nitric acid solution of molybdate 
of ammonia, when a canary-yellow precipitate imme- 
diately forms. 

Calculi, when occurring in the urine, although 
indicating no direct disease of the kidneys and urinary 
apparatus, do indicate, by the particular kind, the 



URINARY SEDIMENT AND CALCULI. 



59 



special diathesis which is being established in the 
system, and 'which, in due course of time, will even- 
tuate in disease of the urinary organs. Sediments, 




Fig. 15. — Oxlate of Lime Crystals. 
a, b. Octahedra. c. Compound Forms, d. Dumb-bells. 

too, which precipitate out immediately or a short time 
after voiding the urine indicate a strong tendency to 
the formation of concretions. 



CHAPTER VII. 

DIFFERENTIAL DIAGNOSIS OF CHRONIC BRIGHT'S 
DISEASE, BASED ON A CLASSIFICATION OF THE 
NORMAL ABSOLUTE, THE ABSOLUTE, AND THE 
RELATIVE ABSOLUTE OF SOLIDS AND UREA 
FOUND IN URINE WITH ALBUMIN AND WITH 
OR WITHOUT TUBE-CASTS. 

In using the term chronic Bright's disease instead 
of chronic nephritis, I know I yield to a popular, but 
at the same time, I must say, most generally well- 
understood condition of the patient, if not of his 
organ affected. 

It is quite true that the cases described by Richard 
Bright in 1827 are not those seen by us to-day under 
the title of chronic, but rather belong to the acute 
form of the malady, which, in our experience, is 
usually a self-limited disease, and will run its course 
and leave the patient generally without damage, 
provided it has been properly cared for. By chronic 
Bright's disease, therefore, I wish to indicate a far 
more formidable malady — a disease which at times 
comes on most stealthily, and after making certain 
headway is beyond cure. I include, then, under and 
in this category the large white kidney, the small 

60 



CHRONIC BRIGHT'S DISEASE. 



6l 



granular kidney, the small granular and fatty kidney, 
and, finally, the amyloid or waxy kidney. 

Tube-casts. — Tube-casts are considered to be 
fibrinous molds of the kidney tubules, and they fre- 
quently are mixed with blood- or pus-corpuscles, 
granular matter, epithelial cells, various crystals, 
and oil drops. When mixed with the epithelial 
cells, they are called epithelial casts; when containing 




Fig. 16. — Coarsely Fig. 17. — Acid Fig. 18. — Fig. 19. — Blood- 
Granular Casts. Sodic Urate in Leukocyte Cast. 
Cylinders. Cast. 

oil drops, fatty casts, or oil casts, and when appearing 
as perfectly clear and transparent cylinders, having 
the same refractive power as urine, they are termed 
hyaline casts. 

Blood-casts, as their name implies, contain blood- 
corpuscles, and are indicative of acute inflammation 
of the kidneys. 

Granular casts are those containing granules, 



62 



DIAGNOSIS BY THE URINE. 



large or small, and are composed of granular matter 
coming either from the breaking-up of the epithelial 




Fig. 20. — Hyaline Casts. Fig. 21. — Epithelial Cast. 




o 



Qo 



Od 



Orf> 



4>0 



Q> U o 0g. 



O 



CD S 



<30 ° 



Fig. 22. — Finely 
Granular Cast. 



Fig. 23. — Peculiar Changes of the 
Red Blood-corpuscles in Hematuria. 



cells and blood-cells, or else from the material of 
which the cast itself is composed. When of the 



63 

dense and coarsely granular type, they are very 
indicative of chronic interstitial disease. 

Mucous casts are frequently mistaken for regular 
tube-casts, but the absence of albumin, together with 
the other conditions of the urine to be elaborated, 
will render a mistake in diagnosis in these cases highly 
reprehensible. Hyaline casts, too, even in urine 




Fig. 24. — Crenated Red Blood-corpuscles 
in Renal Hematuria. 



without albumin, are not rare in the experience of the 
author; but the other guides to diagnosis, soon to 
be given, will prevent mistaking these kind of cases 
for true Bright's disease. 

Finally, cast-like formations of the urates may 
be mistaken for granular casts, as they bear some close 
resemblances to the same; the rounded ends of the 
real tube-casts, however, will avoid such a mistake, 



64 



DIAGNOSIS BY THE URINE. 



which very distinctive feature is not found in these 
false casts. 

Cases Classified According to the Absolute, 
the Normal Absolute, and the Relative Absolute. 

— By absolute we mean the total quantity of solids 




Fig. 25. Deposits in Acid Fermentation of Urine. 

a. Fungus, b Amorphous Sodium Urate, c. Uric Acid. 
d. Calcium Oxalate. 



and urea found in any urine, irrespective of the 
quantity passed. 

By normal absolute we mean the total quantity 
of solids and urea as contained in a normal elimination 
of urine of twenty-four hours. It is, therefore, the 
same, or nearly so, as the relative absolute. Finally, 



CHRONIC BRIGHT'S DISEASE. 65 

by the relative absolute we mean the amount of solids 
and urea as compared with the normal absolute. 

In health the normal absolute of solids varies 
from 60 to 70 grams, and urea 30 to 35 grams; the 
quantity of water passed also in winter varies from 
1200 c.c. to 2000 ex., and in summer from 900 c.c. 
to 1500 c.c; the specific gravity, too, according to this 
variation in quantity of urine passed, shows a range 
in winter of from 1.013 to 1.022, and in summer of 
from 1. 01 7 to 1.030. If, however, a urine containing 
no albumin and no sugar shows an increase of the 
absolute, it is an evidence of a condition of baruria, 
generally due to excessive elimination of phosphates 
or else urea. To make certain, therefore, which it is, 
make an estimation of the absolute urea, and note 
its quantity; if this be normal, then the increase in 
solids is, no doubt, due to phosphates; should sugar 
be also present, the estimation of its quantity, or else 
of that of the phosphates, will give the information 
desired. 

The absolute without the presence of albumin is 
increased in conditions of the system attended with 
great loss of flesh, and is technically called baruria. 
The normal absolute, again, remains constant, or 
increases with corresponding increase of relative 
absolute, in all conditions of congestion of the kidneys; 
this condition of things is markedly shown in heart 
disease, where, too, albumin and tube-casts fre- 
5 



66 DIAGNOSIS BY THE URINE. 

quently occur. To differentiate, then, this from 
chronic Bright's disease is sometimes very difficult; 
the history, however, of the case previous to the heart 
lesion, together with the gradual lessening of the 
urine and increase of solids and urea, will tend to 
exclude chronic Bright's disease, which, in the ex- 
perience of the author, has never given such a clinical 
picture of the urine. 
Classification of Cases. — 

I. Absolute solids, 60 to 70 grams; with relative 
absolute, 60 to 70 grams — of which urea is found 
to be 30 to 35 grams, with relative absolute, 30 to 
35 grams; no albumin, no sugar, and no tube-casts — 
constitutes an absolutely healthy condition of the 
kidneys. 

II. Absolute and relative solids, sixty grams or 
more, of which urea is found to be twenty grams 
or less, with albumin, and, in those nearing middle 
life, attended or not with appearances of tube-casts 
of only, say, the hyaline type, is a sign of chronic 
Bright's disease. To this class belong the so-called 
junctional albuminurias in young people, not commonly 
met with after twenty years of age, but most frequently 
encountered about the age of puberty. In these 
cases, too, the absolute and relative absolute of urea 
is found generally to run twenty or more grams 
instead of less. 

III. Absolute and relative absolute solids, sixty 



CHRONIC BRIGHT'S DISEASE. 67 

grams or less, of which urea is found to be twenty 
grams or less, points strongly to some disorganization 
of the liver, provided no albumin is found. 

As a specimen of this kind of urine I append the 
following analyses of a case which, on October i, 
1898, showed only 9.75 grams of urea, and after 
treatment for a month and over showed as follows: 

Analysis made October 26, 1898. 

Quantity of urine passed in twenty- 
four hours, 1450 ex. 

Specific gravity, 1.014 

Reaction, , . Acid. 

Albumin, None. 

Sugar, 

Absolute solids, 48.49 gm. 

Absolute urea, 17-40 " 

Second analysis, made November 14, 1898. 

Urine passed in twenty -four hours, 1150 c.c. 

Reaction, Acid. 

Specific gravity, 1.021 

Albumin, None. 

Sugar, 

Absolute solids, 56.26 gm. 

Absolute urea, 21.22 " 

As the patient is under treatment, there is no benefit 
derived from making a calculation as to the relative 
absolutes, which gives us only the physiologic action 
of the kidneys when they are under no stimulation 
save that of the weather. 

IV. Absolute solids, forty grams or less, of which 
urea is found to be twenty grams or less, without 
albumin, is no sign of chronic Bright's disease, but 



68 DIAGNOSIS BY THE URINE. 

simply an evidence, generally, of some neurasthenic 
condition in which the solids carried to the kidneys 
for excretion are below the normal, and not that the 
eliminative capacity of the kidney is in any wise 
affected; these cases have been described by Sir 
Andrew Clark as cases of " renal inadequacy," but 
which, in the author's experience, seem due to the 
cause above mentioned. 

In the author's experience, when the kidneys 
are really damaged, these cases show a slight quantity 
of albumin in the urine, and also fail to respond so 
readily to a salt diet when instituted. 

This test of the salt diet is applied in the following 
manner: The patient is given thirty or more grains 
of chlorid of sodium each day, preferably in the form 
of a tablet devised by the author for anemia and 
Bright's disease, and manufactured by Messrs. 
Parke, Davis & Co., of Detroit, Michigan, under 
the name of Salt and Iron Tablets. Three or four 
of these tablets are given each day, and afterward the 
urine examined daily, when, if it be a case not com- 
plicated with chronic kidney lesions, the urine im- 
mediately shows an improvement in the absolute 
solids excreted, and frequently in a greater relative 
than calculated, showing thus a more concentrated 
urine. These neurasthenic urines are generally great 
in quantity, but very low in specific gravity. 

V. Absolute solids sixty grams or more, of which 



CHRONIC BRIGHT'S DISEASE. 69 

urea is found to be thirty or more, but in which the 
relative absolute solids are less than fifty grains, 
of which the urea is found to be less than twenty 
grams, with the slightest show of albumin, and with 
or without hyaline, granular, and epithelial casts, 
are, in my experience, an unfailing sign of chronic 
Bright's disease. The interstitial variety of kidney 
degeneration most commonly shows this kind of 
urine, and begins in this way, but at times it becomes 
hard to determine whether it belongs to this or rather 
to the chronic parenchymatous form; the appearance, 
however, of much and general edema, the greater 
quantity of albumin, and the comparative youth 
of the patient (between twenty-five and forty-five), 
would point to chronic parenchymatous degeneration 
rather than to interstitial growth and contraction. 
As a specimen of the urine under these conditions, I 
place the following, taken from my case-book, from a 
. gentleman under my care now for several years, and for 
whom I at regular intervals carefully examine the urine : 

Age of patient, fifty-four. 
Analysis made January 6, 1897. 
Quantity of urine passed in 

twenty -four hours, 3480 ex. 

Reaction, Slightly acid. 

Specific gravity, 1.010. 

Albumin, Considerable quantity. 

Absolute solids, 81.08 gm. 

" urea, S 1 ^ 2 " 

Relative absolute solids, 46.60 " 

" " urea, I 7-99 " 



70 DIAGNOSIS BY THE URINE. 

In regard to the relative solids and urea, the calcu- 
lation has been based on the passage of 2000 c.c. as 
being physiologic, which, at the time of the year the 
analysis was made, I consider an allowable maximum; 
cold weather and easterly winds laden with moisture 
having, in the experience of the author, sometimes 
on healthy kidneys far more diuretic effects than the 
strong drugs we frequently give for a like purpose 
in diseased conditions. Since the above analysis 
represents, in this class of interstitial cases, probably 
the best phase of the disease, I append another, which 
more nearly represents what the general practitioner 
will meet with in regular and uncomplicated cases: 

Age of patient over fifty years. 
Date of analysis, March 27, 1907. 
Quantity of urine passed in twenty- 
four hours, 3 2 4° c. c. 

Reaction, Slightly acid. 

Specific gravity, 1.007. 

Albumin, Very slight amount. 

Absolute solids, 52.84 gm. 

" urea, 21.06 " 

Relative absolute solids, 3 2 -59 " 

" " urea, 13-°° " 

Having cited, now, two cases as specimens of 
the urine in male patients in the interstitial form 
of chronic Bright's disease, I take again from my 
case-book an interstitial renal affection occurring 
in the female, and in which the urine showed as 
follows : 



CHRONIC BRIGHT'S DISEASE. 7 1 

Analysis made December 11, 1895. 
Patient, woman fifty-five years of age. 
Quantity of urine passed in twenty- 
four hours, 1560 c.c. 

Reaction, Slightly acid. 

Specific gravity, 1.018. 

Albumin, Slight amount. 

Absolute solids, 65.42 gm. 

urea, 23.40 " 

As the quantity of solids in the urine passed here 

is a physiologic amount, no calculation as to the 

relative is necessary. The presence, however, of 

albumin regularly with this kind of urine, and after 

thirty years of age, in the experience of the author 

relegates the condition into one of renal degeneration, 

and very soon we note in these cases a change in the 

urine in which the solids and urea fall absolutely and 

relatively, or else the relative absolute solids and urea 

increase, thereby showing diminished excretion of 

water. As an evidence of this T will give two more 

examples of urine taken from this same patient, but 

will add that the patient did not die until nearly three 

years and a half had elapsed from the time at which 

the urine showed this normal passage of solids and 

urea. This is an important fact to note, since, in the 

experience of the author, the signals of an approaching 

end are to be seen by comparing the absolutes and 

relative absolutes. 

Analysis made January n, 1896. 

Urine passed in twenty -four hours, 1470 c. c. 
Reaction, Slightly acid. 



72 DIAGNOSIS BY THE URINE. 

Albumin, Considerable amount. 

Specific gravity, 1.018. 

Absolute solids, 61.65 gm. 

" urea, 2 3-5 2 " 

Without now giving a number of analyses showing 
a lessening of the absolutes which occurred, I will 
place for your attention one made six months before 
the patient died; it was as follows: 

Analysis made October 27, 1897. 
Quantity passed in twenty-four- 
hours, 1380 c.c. 

Reaction, Neutral. 

Specific gravity, 1.009 

Absolute solids, 27.26 gm. 

urea, 8.50 " 

Relative absolute solids, 29.63 " 

" " urea, 9.23 " 

The relative absolute solids and urea have been 
calculated on a basis of 1500 c.c. as being physiologic 
at this time of the year in Charleston, S. C. ; as it is 
usually warm, it being only during cold weather, and 
particularly when attended with easterly winds, that a 
maximum allowance to the amount of 2000 c.c. has 
seemed a proper gauge to consider within the range 
of health. 

I have said that occasionally we find in this kind 
of kidney degeneration urine showing at times not 
even a trace of albumin when the tests are applied 
in the ordinary way; this, I think, is due to the ex- 
treme tenuity in which the albumin is held in solution. 



CHRONIC BRIGHT' S DISEASE. 73 

If, then, in these clear urines you evaporate below 
the boiling-point until half their bulk, or until the 
solids just begin to show on account of the abstraction 
of water, then the same tests applied will not give 
negative results. 

As urines of this description I append the following 
from a female patient who died of interstitial nephritis: 

Analysis made November 17, 1896. 

Urine passed in twenty -four hours, 2310 c.c. 

Reaction, Neutral. 

Specific gravity, 1.004 

Albumin Mere trace. 

Absolute solids, 21.43 gm. 

urea, 4.62 " 

Relative absolute solids, 18.55 " 

urea, 4.00 " 

Analysis made February 6, 1897, of urine from same patient: 
Urine passed in twenty-four hours, 840 c.c. 

Reaction, Slightly acid. 

Albumin.. None by tests ap- 
plied in the usual 
way. 

Specific gravity, 1.013 

Absolute solids, 25.44 gm. 

urea, 9.24 " 

Relative absolute solids, 60.56 " 

urea, 22.00 " 

As before said, when the analyses are made in cold 
weather, 2000 c.c. must be considered as physiologic- 
ally permissible, but during the winter or fall, if the 
weather is warm and balmy, a general average of 1500 
c.c. will be nearer right on which to base the calcula- 



74 DIAGNOSIS BY THE URINE. 

tion of relative solids and urea. Should the analyses 
be made in summer, in the experience of the writer 
a minimum of 900 c.c. or maximum of 1500 c.c. 
is permissible in health. 

VI. Under this head we place those cases in which 
the absolute solids are thirty grams or less, and of 
which the urea is found to be ten grams or less, with 
relative absolute solids twenty grams or more and urea 
ten grams or more, with small or large show of albumin 
and with or without hyaline, granular, or epithelial 
casts. These are truly cases of chronic Bright's 
disease in their last stages, which may have been 
preceded by either the amyloid kidney, the large 
white kidney, the fatty kidney, or else the granular 
or contracted kidney. As an example of urine of 
this description I append the following analysis: 

Analysis made October 27, 1897; patient, female.' 

Urine passed in twenty -four hours, 1380 c.c. 

Reaction, Neutral. 

Specific gravity, 1.009 

Albumin, Small amount. 

Absolute solids, 27.26 gm. 

urea, 8.50 " 

Relative absolute solids, 29.63 " 

urea, 9.23 " 

The relative solids and urea are calculated on a 
basis of 1500 c.c, but really for diagnostic and prog- 
nostic purposes, when the urine shows so low an 
absolute amount of solids and urea as in the above 



CHRONIC BRIGHT S DISEASE. 75 

analysis, it is unnecessary to calculate what it would be 
to a normal excretion of solids and urine respectively. 

It may be, however, broadly stated that when the 
relative absolute solids and urea rise in the neighbor- 
hood of what the normal absolute ought to be, at the 
expense of the absolutes, then the case is very near to 
a close; thus, in the case already cited, at w r hich the 
analysis was made a few months prior to death, it 
will be seen that the relative absolute solids were 
60.56 grams and the relative absolute urea 22.0 grams, 
whereas the absolute solids were 25.44 and urea 
9.24 grams. 

I now append the result of my analyses of a few 
more specimens of urine taken from patients still 
alive, and some of whom have passed away, to show 
how long persons can live with interstitial degener- 
ation of the kidneys, even when the solids and urea, 
absolutely and relatively, the one or the other, are 
high or low. 

Case I. — Patient, male; age about fifty, still alive, 
and apparently enjoying good health. 

Analysis made April 24, 1895. 

Urine passed in twenty-four hours, 3250 ex. 

Reaction, Acid. 

Specific gravity, 1.006 

Albumin, Very slight amount. 

Absolute solids, 45-43 g m - 

11 urea, 20.15 " 

Relative absolute solids, 20.96 *' 

urea, 9.60 " 



76 DIAGNOSIS BY THE URINE. 

The relatives have been calculated on a basis of 
1500 c.c. of urine as normal for this time of the year. 
It may be said of this patient that he has regularly 
taken my salt and iron tablets, and this analysis only 
represents, then, his condition before he began 
treatment. 

Case II. — Patient, female. 



Analyses made November 21, 1894, December 1, 1894, De- 
cember 6, 1894, December 18, 1894. 
Analysis of November 21, 1894. 

Urine passed in twenty-four hours, 2240 c.c. 

Reaction, Alkaline. 

Specific gravity, !-o°5 

Albumin, Little. 

Absolute solids, 26.09 g m - 

11 urea, 6.72 " 

Relative absolute solids, 23.29 " 

" " urea, 6.00 " 



Analysis of December 1, 1894. 

Urine passed in twenty-four hours, 2160 c.c. 

Reaction, Alkaline. 

Specific gravity, 1-005 

Albumin Little. 

Absolute solids, 25.16 gm. 

urea, 7.53 " 

Analysis of December 6, 1894. 

Urine passed in twenty -four hours, 1320 c.c. 

Reaction, Acid. 

Specific gravity, 1.010 

Albumin, Very little. 

Absolute solids, 3°-75 gm- 

urea, 7.92 " 



CHRONIC BRIGHT'S DISEASE. 77 

Analysis of December 18, 1894. 

Urine passed in twenty-four hours, 1500 c.c. 

Reaction, Slightly acid. 

Specific gravity, 1.012 

Absolute solids, 41 .94 gm. 

" urea, 11. 10 " 

This patient died in the spring of 1898, showing 
at that time, and six months before, an increase of 
the relative absolute of solids and urea at the expense 
of the absolute, thus evidencing extreme dilatation 
of the heart. In summarizing, then, the lessons to 
be taught by these analyses, and many more I could 
give, I will say a few words about tube-casts, since 
it will be observed that I do not state in these analyses 
whether or not I found them. This I have purposely 
done, as I have for a long while contended that it 
was, in the vast bulk of cases, entirely unnecessary 
to look for them when other clinical features were 
present in the urine, and which, when found, were 
far less misleading than the occasional finding, say, 
of hyaline, and at times even granular, tube- casts 
in the urine of one past middle age, and in other 
respects in good health. 

What, then, are the clinical features that make 
tube-casts not misleading, and upon which we rely 
in making a differential diagnosis of chronic renal 
affections? My answer is: First, the presence of 
albumin in the urine; second, a diminution in the 
relative absolute solids and urea, with a normal 



78 DIAGNOSIS BY THE URINE. 

quantity of solids and urea {not normal absolute, 
which refers also to normal quantity of urine) or an 
excessive amount of absolute solids and urea; third, 
an increase in the relative absolute solids and urea 
at the expense of the absolute. 

If, with these conditions, tube-casts are found, 
they make us doubly sure of our diagnosis, whereas 
their absence would not with us exclude chronic 
Bright's disease. 

In our observations tube-casts are not found to 
any extent, unless in urine in which the above con- 
ditions have been fulfilled; and when they are occa- 
sionally seen in urine which does not react as just 
set forth, we think chronic renal lesions may be 
excluded. 

Tube-casts have generally been divided into the 
hyaline — broad and slender — the granular, and the 
epithelial; frequently, we meet with one and some- 
times with all in chronic Bright's disease, and w r ere 
it thus only in these affections that they are met with, 
why then we would have a sure means of diagnosticat- 
ing Bright's disease; as this is not the case, however, 
we must fortify their finding with the other clinical 
features already elaborated, and which, in the ex- 
perience of the writer, has failed less often than 
w r hen tube-casts, and especially of the hyaline type, 
were taken as evincing a disease of the kidney. 

Finally, there are certain fevers — and if our knowl- 



CHRONIC BRIGHT S DISEASE. 79 

edge were greater, I feel sure the list would be much 
enlarged — which are attended at their commencing 
stages with symptoms which, by the novice, might 
be taken for acute, but hardly for chronic, Bright's 
disease — to wit: an appearance of albumin and tube- 
casts. As far, however, as my experience goes with 
this class of cases, I am not aware that the other 
clinical features of the urine already stated are met 
with unless a chronic affection is coincident with the 
fever. As the fever advances, the clinical features 
of the urine are so changed that he would be a bold 
— yes, rash — diagnostician, who would venture an 
opinion as to the real state of the kidneys; at the 
beginning of the attack, or else when convalescence 
is well established, should be the time to definitely 
determine if the kidneys are really diseased. 

The infective diseases are those in which these 
changes of the urine are observed, and most markedly 
in the author's experience in pneumonia, typhoid 
fever, diphtheria, and scarlet fever; that it occurs in 
some others is equally true, as some of the recent 
text-books used in our medical colleges will show. 

The author would also add that during the parox- 
ysms of malarial fever albumin is frequently found 
in the urine, together with tube-casts and blood- 
corpuscles. If the paroxysms are not quickly relieved 
by proper medication, the albumin continues in the 
urine for some length of time, even after the patient 



80 DIAGNOSIS BY THE URINE. 

is up and about. This malarial poison is, therefore, 
in my experience, a prolific cause for degeneration 
of the kidney when allowed to remain in the system; 
and though during an attack of malarial fever one 
may expect frequently to meet with cases showing 
albumin and tube-casts in the urine, after the fever 
is over, if the kidneys are not damaged, these abnormal 
products should vanish. 

In health the normal and relative absolutes of solids 
should be either the same or range between sixty 
and seventy grams. In disease, however, they vary 
much; as a means, then, for comparing these variations 
I append the following tables, and will designate 
them a, b, c, respectively, dividing these also into 
four stages. 

The estimation of relative absolute is calculated 
from the total solids or total urea as compared to a 
normal passage of urine in 24 hours: thus, patient 
passed in 24 hours 3000 c.c. with a total passage of 
30 grams of solids. What is the relative absolute? 

3000 c.c. : 30 grams : : 1500 c.c. : R. A. 
which thus is 15 grams. 



(a) In Health without Albumin. 

Solids. N. A. 60 to 70 gm. R. A. 60 to 70 gm. 

a 
Urea. N. A. 30 to 35 gm. R. A. 30 to 35 gm. 



CHRONIC BRIGHT S DISEASE. 



(b) In Disease and with Albumin. 
Solids 



A. 60 gm. or more. R. A. 50 gm. or less. 
A. 50 " " R. A. 40 " 



Solids. 



A. 40 " " R. A. 30 " 

A. 30 " " R. A. 20 " 

or else 

A. 40 gm. or less. R. A. 60 gm. or more. 

A. 30 " " R. A. 45 " 

A. 20 " 4 ' R. A. 30 " 

A. 10 " " R. A. 20 " 



Urea. 



Urea 



(c) In Disease and with Albumin. 

f A. 30 gm. or more. R. A. 20 gm. or less. 

1 A. 20 " " R. A. 15 " 

A. 15 " " R. A. 10 " 

A. 10 ' ; " R. A. 5 " 

or else 

{ A. 20 gm or less. R. A. 30 gm. or more. 

J A 15 " " R. A. 20 " 

] A. 10 " " R. A. 15 " 

[A. s " " R.A. 7 " 



A., the absolute; N. A., the normal absolute; R. A., the relative 
absolute. 

On comparing these tables, then, it will be seen 
that the absolute decreases and the relative increases 
with albumin, with or without tube-casts, in the final 
months of chronic Bright's disease; and that the abso- 
lute increases and the relative absolute decreases in the 
commencing stages of chronic Bright's disease, and 
generally continues to do so, or may, by proper treat- 
ment, be made to do so, until the stage of dilatation of 
the heart is established. 

In the experience of the author a urine which, 
under strong stimulation of the kidneys, shows of 
6 



82 DIAGNOSIS BY THE URINE. 

absolute solids thirty grams or less, and relative 
absolute forty-five grams or more, is an evidence 
of the utter hopelessness of the case; so long as the 
relative absolute can be made to descend and the 
absolute to ascend, we should not despair; but so soon 
as the reverse is actually established, why then all 
treatment is of no avail, and the end must and will 
come. 

Finally, the inference drawn from the above tables 
may be succinctly stated as follows: In urine con- 
taining albumin: 

i. The absolute nearly what the normal absolute 
would be. 

2. The absolute increased and the relative absolute 
decreased. 

3. The absolute decreased and the relative absolute 
increased. 

No. 1 represents the starting stage of chronic 
kidney lesions, and generally the so-called functional 
albuminurias begin in this way; occasionally, however, 
even in advanced cases, by strong stimulation the 
kidneys may for a time show this kind of urine, but 
they very soon lapse into the third stage, and after so 
doing run the regular course, showing diminution of 
solids absolutely and increase relatively. 

No. 2 represents what is seen in the advancing 
stages of kidney lesions, and may extend over many 
years. 



CHRONIC BRIGHT'S DISEASE. 83 

No. 3 is sometimes the natural consequence of 
what has preceded in No. 2, and brings us nearer 
the end of the disease. 

Inasmuch, then, as the determination of the normal 
absolute and relative absolute is, with us, of such 
importance for making a correct diagnosis, as well 
as prognosis, I will now say a few words as to the 
taking of the quantity and specific gravity of the urine : 

I. No urine should be collected from any person 
who is undergoing any treatment whatsoever. 

II. If such be the case, treatment should be inter- 
mitted until a few days have allowed the medicines to 
pass from out of the urine. 

III. The individual should only be allowed as a 
drinking beverage rain, well, or spring water, so 
that the excreting capacity of the kidneys may be 
physiologically gauged: an allowance each day, in 
winter, of not less than three tumblerfuls if soup is 
not taken, or two if it is; and in summer, under the 
same conditions, of not less than six; or four will be 
sufficient with a good ordinary average diet of food 
not excluding tea or coffee — one or the other at break- 
fast and at night, if that has been the custom of the 
individual whose urine you are examining. Although 
these quantities represent, in our experience, a good 
average in adults of sedentary habits, they would 
have to be increased if the person indulged in exercise 
just before the examination. 



84 DIAGNOSIS BY THE URINE. 

IV. And, lastly, the specific gravity should be 
taken and solids calculated on the basis of 6o° F.; 
and for every 5.5 increase in temperature of the urine 
above that, an addition of one degree must be made 
to the reading. Thus, if the patient passed a urine of 
specific gravity 1.016, temperature 8o°, it would read 
1. 0196. 

Before concluding, I deem it well to say a few 
words in regard to neurasthenia in persons suffering 
from chronic Bright's disease. When this condition 
is coincident with kidney lesions it makes a prognosis 
at times very difficult, and it is only by repeated ex- 
aminations of the urine that this source of error can 
be eliminated. For example, we have seen in an 
interstitial nephritis an average analysis of the urine 
show 68.50 grams of absolute solids and 27.93 grams 
of absolute urea, and during a nervous condition we 
have seen the same urine show less than forty grams of 
absolute solids with less than fifteen grams of urea. 
Most assuredly, then, a prognosis based on this latter 
analysis would be misleading, and would lead us into 
giving too grave a prognosis as to the immediate future 
of the patient. A continuous neurasthenic affection, 
whether or not induced by the kidney lesion, is, in our 
experience, a grave complication, and will much 
shorten the life of the individual; but a transient and 
occasional array of neurasthenic symptoms does not 
portend so seriously. 



CHRONIC BRIGHT'S DISEASE. 85 

Finally, as life insurance is getting to be a matter 
of great importance and everyday occurrence, I shall 
conclude this chapter by giving the following rules, 
which, it is thought, will aid the examiner in avoiding 
bad risks and accepting those which, by the author, 
seem legitimate ones: 

Rules for Life Insurance Examiners. 

Rule I. — View with suspicion any specimen of 
urine containing albumin, and be especially cautious 
if the specimen at the same time during the winter 
months shows a winter minimum of 1.013 specific 
gravity, or else during the summer the minimum of 
1. 017. 

Rule II. — Reject any urine after middle age 
containing albumin with the absolute solids and 
urea either normal or else increased and the relative 
absolutes decreased. 

Rule III. — Reject a urine showing albumin and a 
decrease of absolutes with an increase of relative ab- 
solutes. 

Rule IV. — Do not regard after middle age the 
occasional finding of tube-casts, hyaline and some- 
times granular, as militating against insurance if 
the absolutes and relative absolutes are normal and the 
urine is also free from albumin. 

Rule V. — Never report a urine free of albumin 
in which the absolutes and relative absolutes appear as 



86 DIAGNOSIS BY THE URINE. 

in Rules II and III, unless you have evaporated the 
urine below boiling to a point at which the solids begin 
to precipitate out, and to which condensed urine you 
have applied the tests for albumin. 

The view, then, held by us as to the value to be 
attached to the finding of tube-casts in the urine, al- 
though opposed to that usually taught, is based upon 
the experience of the author, extending over several 
years, with cases most carefully watched. He is 
aware, therefore, that he may encounter much op- 
position from the profession in accepting his ex- 
perience as a guide for safety, and especially from 
examiners of life insurance companies, who pay, we 
think, far too much attention to the finding of tube- 
casts in those past middle age, and too little to the 
other clinical features which we have tried to clearly 
set forth as far more certain guides. We feel, then, 
that tube-casts after middle life are often but the 
expression of natural, and not of serious, pathologic 
changes going on in the kidneys, together, we believe, 
with similar changes in other organs, with the ex- 
foliations of which science at present is not sufficiently 
familiar. We are led to this conclusion from the 
following facts: 

First, that kind of kidney lesion attended with a 
large show of tube-casts is curable, or, rather, self- 
limited, and generally leaves the kidney uninjured. 
I refer to acute Bright's disease. Surely, here the 



CHRONIC BRIGHT'S DISEASE. 87 

epithelial lining of the tubules is replaced, or else the 
kidney would not do its work as before the attack, 
which factor — its capability of doing its former work — 
is the only true gauge to judge a kidney by. 

Second, that kidney lesion which is far beyond cure, 
but which sometimes extends over many years, is 
frequently attended with but few tube-casts. In this 
kidney degeneration surely the exfoliation of a few 
tube-casts can not be looked upon as of so serious 
import, or as the cause of the final changes found in 
this kidney. It will also be noted that their presence 
gives us no data by which to formulate a prog- 
nosis. 

This change in the cirrhotic kidney and epithelial 
lining of the tubules appears to us to be more in the 
way of crowding out by the condensation of kidney 
tissue into connective-tissue substance. The most 
fatal and short-lived form of kidney lesion in my 
experience has been the large white kidney. Here 
the epithelial lining is not only inflamed and exfoliated 
in large masses, but the entire kidney is in a state of 
subacute inflammation and congestion. These two 
processes, therefore, working together, if not relieved, 
most absolutely change the excreting capacity of the 
kidney. So we have increased exudation of albumin 
from the continued pressure and hydremic condition of 
the blood, and also the copious appearance of tube- 
casts, due to inflammation not only of a chronic 



88 DIAGNOSIS BY THE URINE. 

character, but at times of a subacute and even acute 
form, attended with fever. 

This acute exacerbation grafted on a chronic 
kidney lesion is far more often, in my experience, met 
with in the large white kidney than in the true cir- 
rhotic; that it may occur in this form of kidney- lesion 
is no doubt true, but of its general occurrence we 
think less likely. With us, too, the large wdiite kidney 
has always been far more sensitive to atmospheric 
changes and gastric disturbances than the cirrhotic. 
The possibility, however, of conducting by judicious 
treatment the large white kidney into the secondary 
and finally atrophic form is always to be kept in mind, 
for in so doing life may be prolonged and a miserable 
and distressing train of symptoms relieved. 

Third, and lastly, the exfoliation of kidney tissue 
in the form of tube-casts is now by some admitted 
to frequently take place when toxins occur in the 
blood, and which, when eliminated, leave the kidney 
unhurt. 

With these reasons, then, for taking this view in 
regard to tube-casts, I conclude this chapter. 



CHAPTER VIII. 

RESUME. 

THE DIAGNOSIS OF DISEASES OF THE KID- 
NEY AND URINARY ORGANS. 

All forms of kidney degeneration are due to one 
of three causes: 

i. Hyperemia, which, when active, is called acute 
congestion, and when passive, chronic congestion. 

2. Irritation; this is almost always active in its 
character, and sooner or later eventuates in inflam- 
mation, or else, taking a more chronic or subacute 
course, brings about those pathologic changes which 
are termed capillary arterio-fibrosis. 

3. Inflammation; this, too, is either of an acute 
and active form, or else of a more chronic and sub- 
acute character. The causes or class of causes which 
bring about this condition of things are either direct 
or indirect, the first class inducing active inflammation 
and the second an inflammation of a more chronic 
course. 

To differentiate these several phases of kidney 
disease requires, at times, a good deal of well-directed 
patience and perseverance. Important is it, however, 

89 



90 DIAGNOSIS BY THE URINE. 

for on the right appreciation of the case not only 
depends a proper prognosis, but at times the very 
life of the patient itself. 

Hyperemia, whether active or passive, is not in 
itself a disease of the kidneys, but simply the expres- 
sion of a condition which, if unrelieved, will eventuate 
in disease. The appearance of and morbid anatomy 
of the kidneys undergoing this process are important 
to us only as a pathologic study for future infor- 
mation. The appearance and character of the urine 
passed during this period, on the other hand, are of 
great practical use and importance, as they can be 
gathered during life, whereas the pathologic study 
begins only when life is extinct. The differential 
diagnosis between active and passive congestion is 
made as follows: 

In active congestion we have a complaint coming 
on suddenly; in passive, coming on gradually. In 
active congestion the arterial system is in a high state 
of tension; in passive, the tension is low. In active 
congestion the urine is suddenly decreased in quantity 
or else normal, specific gravity normal, and little or no 
albumin ; in passive, the urine will be observed to have 
decreased from day to day, to contain more albumin, 
to have increased in specific gravity and depth of 
color, and to have, on standing, a decided sediment 
of the salts which precipitate out from the diminished 
volume of water. If this condition be allowed to 



RESUME. 91 

continue very long, albumin increases to great quan- 
tities in the urine, and with the increase the patient 
becomes anasarcous; if the cause of the venous stasis 
can not be removed, the case rapidly goes into nephritis 
of a chronic character. The time at which this 
change takes place is always marked by ^.decrease of 
specific gravity (under 1.018), and the appearance, 
generally, of granular and tube-casts. Should active 
hyperemia run on uncontrolled, the case is more apt 
to develop into one of acute nephritis. 

The direct causes of active hyperemia are usually 
sudden variations between the surface and central 
temperatures of the body, brought about by chilling 
the body in various ways. 

Passive hyperemia, or renal stasis, is due to ob- 
structive causes — such as occur in heart, lung, and 
liver diseases — chronic peritonitis with effusion, 
hydatid tumors, pregnancy, and, in fine, to all sources 
which obstruct the direct, or else the return, blood- 
supply of the kidneys. In both forms of hyperemia 
the temperature of the body is not increased unless 
some intercurrent affection is also present. I may 
finally add that, as a further means of diagnosing 
these two conditions, the effect of diuretics and arterial 
tonics and sedatives may be made use of. 

In active congestion diuretics and arterial tonics 
which owe their diuretic action to an increase of the 
tension of the blood are pernicious, whereas sedatives 



92 DIAGNOSIS BY THE URINE. 

or diuretics which increase the flow of urine by simply 
increasing the transudation of water are beneficial. 
In passive congestion, digitalis, spartein, and caffein 
act with efficiency and promptness, and lose only 
their effect when the obstruction which causes the 
stasis is permanent and increasing. 

PARENCHYMATOUS NEPHRITIS. 

Whether or not this pathologic condition of the 
kidneys is brought about by irritation or inflam- 
mation, preceded or not by acute or passive congestion, 
we recognize but two kinds — acute and chronic; and, 
again, of the acute, two varieties: (i) Ordinary 
catarrh of the tubules of the kidney, similar to an 
ordinary catarrh of the bronchial tubes; (2) a more 
severe form of catarrh of the urine tubes, characterized 
by a profuse exudative secretion; this is known as 
diffuse or croupous nephritis (acute B right's disease), 
and would correspond, taking the comparison above, 
to a severe pneumonitis. The differential diagnosis 
is made as follows: 

In acute catarrhal nephritis we have little or no 
fever; slight bearing and dragging pains in the sacral 
region; small show, and sometimes none at all, of 
albumin, normal or slightly diminished quantity of 
urine, specific gravity normal, reaction acid, usually 
decided sediment, but composed mainly of mucus; 
no edema or anasarca. 



RESUME. 93 

In acute diffuse nephritis we have considerable 
fever, greater feeling of discomfort in sacral region, 
much edema, and sometimes anasarca so great as to 
completely disfigure the individual; large quantities 
of albumin in the urine, increased specific gravity, 
and marked diminution in quantity of water (often 
only 200 c.c. in twenty-four hours) ; large, sedimentary 
deposits, composed mainly of urates, blood-coloring 
matters, and epithelial cells. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

Chronic parenchymatous nephritis may be the 
sequel of an acute attack, but oftener begins as such. 
The first symptom of this disease is dropsy without 
fever; the specific gravity of the urine is always 
found to be below normal, and has a range, generally, 
of between 1.013 and 1.017. When the specific 
gravity falls below this, and shows a lower limit of 
1. 010 or 1. 012, it is an evidence that the nephritis 
is taking on what may be termed a secondary action, 
and is going to become an interstitial variety. The 
quantity of urine passed is generally normal, its reac- 
tion decidedly acid, and its color is generally pale 
yellow. It contains much detritus, frequently con- 
sisting of epithelium of the kidney and various cell 
forms; albumin is always found in considerable 
quantities, ranging from \ of one to 2\ per cent. 



94 DIAGNOSIS BY THE URINE. 

INTERSTITIAL NEPHRITIS. 

This disease of the kidneys is frequently a natural 
consequence of the chronic secondary parenchym- 
atous variety; when it is, the general characteristics 
are somewhat masked, as the change has been gradual. 
The great difference, however, shown in the urine is 
in the smaller quantity of albumin, the increased 
volume, paler color, and specific gravity ranging 
lower — 1.008 to 1. 012. After a little, we note the 
fibrous change the vascular system has undergone, 
and see developed a true capillary arteriofibrosis, 
evidenced by a full, tense pulse, associated with 
hypertrophy of the heart — most apparent on the left 
side. Interstitial nephritis, or cirrhosis of the kidney, 
seldom starts in youth, but most often about the 
middle of life, and without dropsy. For a long time 
there is really nothing to call attention to the disease, 
save the condition of the heart and pulse. If, how- 
ever, together with this indication we find small 
(yes, sometimes very small, and for days at a time 
none) quantities of albumin, impairment of vision, 
diminished specific gravity, and a pale-colored urine 
of normal quantity or else increased, we can safely 
pronounce the case as one of atrophy of the kidneys. 
It is particularly important in these cases to estimate 
the urea from time to time, as a means of better form- 
ing a diagnosis and prognosis. 



RESUME. 95 

As the disease advances, although the volume of 
water increases the urea falls off, and toward the end 
seldom shows more than seven or eight grams for the 
twenty-four hours. The reaction of the urine in this 
variety of kidney disease is acid, and only becomes 
neutral and alkaline when the nephritis is of the sup- 
purative variety; when of this latter kind, the odor 
of the urine is putrid, and it contains blood-coloring 
matters and pus. 

The differential diagnosis between interstitial neph- 
ritis and amyloid kidney is extremely difficult, as the 
general characteristics of the urine are about the same. 
Amyloid kidney, however, has no symptoms of 
capillary arteriofibrosis, and is generally associated 
with some constitutional disease, such as chronic 
tuberculosis, scrofula, malarial cachexia, and syphilis, 
and is frequently accompanied with a certain amount 
of dropsy. 

There is, however, a condition which from the 
author's experience seems to be of wide range, of 
cases showing for long periods no albumin in the 
urine, but in which the absolute of solids and urea 
decrease and the relative increases, showing for a 
long time renal insufficiency and at the post-mortem 
few kidney lesions. These cases seem to him to be 
true evidence of a low and slow grade of sclerosis, in 
which either the liver cells or cells of the small in- 
testines refuse to break up food into its final health 



96 DIAGNOSIS BY THE URINE. 

end products, and thus the kidney excretion shows a 
great diminution of the same. 

These are the cases which are constantly passed 
by the general examiner of urine, and it is only after 
a stroke, may be of paralysis, of syncopy or some 
uremic phenomena, that a more careful examination 
of the urine is made and with it the startling revela- 
tion disclosed of the fall of solids and urea to a point 
where life can no longer be maintained. See table on 
pages 80 and 81. 

As a further aid in determining whether the in- 
sufficiency we have spoken of is functional or organic, 
the estimation of renal permeability by the phloridzin 
method, the methylene-blue method and the cryo- 
scopic method may be taken advantage of. 

Mering's Phloridzin Method. — Inject T V of a grain 
of phloridzin into the subcutaneous cellular tissue; 
glycosuria is produced; healthy cells eliminating more 
in the same time than diseased cells; elimination 
begins in normal cells in about ten or tw r elve minutes, 
whereas in diseased ones later on; by the estimation 
then in one hour of the sugar passed, a fairly good 
idea can be obtained as to the permeability of the 
kidneys. Provided the test is frequently applied. 

Methylene-blue Method. — Inject | of a grain 
of methylene-blue subcutaneously, and note how soon 
and how long the blue color continues in the urine. 
Healthy kidneys excrete it at once and the urine holds 



RESUME. 97 

the color longer than when they are diseased. This 
test too must be frequently applied to avoid errors. 

The Cryoscopic Method.* — Cryoscopy is the name 
given to the process of determining the depression of 
the freezing point of solutions. This method is used 
to determine the molecular concentration of the 
urine, or the renal permeability, by the freezing point 
of this secretion. 

The process is based upon the following facts : 

The freezing point of a solution of a substance in a 
liquid with which it forms no chemical union, is 
lowered below that of the solvent, in direct proportion 
to the number of molecules of dissolved substance in a 
given volume of a solution, or its molecular concen- 
tration. 

This law applies to a solution of several substances 
in the saxiae solvent, as well as to solutions of one 
substance. The depression of the freezing point of 
aqueous solutions is, therefore, a measure of the 
number of molecules in that solution. 

The number of these mixed molecules in an appre- 
ciable volume of urine, say i c.c, is very great. For 
present purposes the relative number is all that is 
needed. The simplest form of apparatus for deter- 
mining the freezing point of urine is that of Claude 
and Balthazard (Fig. 26). It consists of a tube 

*From Prof. Bartley's Physiological and Clinical Chemistry. 
Third Edition. 



98 



DIAGNOSIS BY THE UKINE. 



"a" the freezing vessel, and "&," an outer tube to 
protect "a" The space between these two tubes is 
partly filled with alcohol to serve as a conductor. 
The cylinder A is filled three-fourths full with ether 




Fig. 26. — Apparatus for determining freezing 
point of urine. (Bartley.) 



or carbon disulphide. The wash bottle B contains 
a small quantity of H 2 S0 4 to dry the incoming air. 
The tube c is connected with a water aspirating pump, 
and a current of air drawn through the apparatus, 
which escapes from numerous small holes in the 



RESUME. 



99 



metal inlet tube, coiled on the bottom, of the cylinder 
A, causing the ether to evaporate rapidly, thus pro- 
ducing a low temperature. The temperature can be 
regulated, or kept constant, by regulating the current 



/ 




Fig. 27. — (a) Epithelial Cells from the Male Urethra; (&) from the 
Vagina; (c) from the Prostate; (d) Cowper's Glanks; (e) Littre's 
Glands; (/) Female Urethra; (g) Bladder. 



of air. The liquid, whose freezing point is desired, 
is placed in the tube "a," ether or carbon disulphide 
is put in A, the vessel made tight, the thermometer, 
which should read hundredths of a degree, is sus- 



IOO DIAGNOSIS BY THE URINE. 

pended in the liquid to be frozen, with the platinum 
wire stirrer adjusted as seen in the cut, and the pump 
started. 

From time to time the stirrer is moved up and 
down, until the thermometer becomes stationary at a 
little below o° C. To cause the solution to freeze, 
scrape off a little frost from the outside of A and add 
it to a. It is not necessary to w&it until the liquid is 
all frozen, but until a part is congealed. The tem- 
perature at which normal urine freezes is usually 
— 1.30 C. to — 2.20 C. The extremes are seldom 
met in health. 

The depression of the freezing point is usually 
represented by A. The depression of the freezing 
point, expressed in hundredths of degrees, may be 
arbitrarily used to represent the relative number of 
molecules dissolved in a given volume, say 1 c.c. 
If we represent the number of c.c. of urine voided, in 
24 hours by V, then the total work done by the kidneys 
in 24 hours will be represented by V X A. To 
make more accurate the comparison in different in- 
dividuals, we must take into the calculation the body 
weight of the individual. If we designate this weight 
in pounds or kilograms (2.2 lbs.) by P, the total 
daily work of the kidneys per lb. or kilo, of body 
weight will be represented by 

AX|- 



RESUME. IOI 

Example. — A certain urine gave a depression of freezing point 
( A)» of 1.20 C. The volume of urine was 1,200 c.c. The 
weight was 60 kilogrammes (132 lbs.). The work of the kid- 
neys in this case was 120X1,200-^60=2,400 for each kilo, of 
body-weight. Or, each kilo, gave 2,400 arbitrary molecules of 
urinary solids in 24 hours. 

In health this number should be between 3,000 and 
4.000. In pathological conditions the number is 
above or below these limits. A part of these mol- 
ecules are inorganic, chiefly NaCl, filtered through 
the glomeruli with the water, and the rest organic, 
separated from the blood by the tubular epithelial 
cells. According to the theory of Ludwig, as modified 
by Koranyi, there filters through the glomeruli nearly 
a pure solution of NaCl, containing too small a 
quantity of the other inorganic salts to appreciably 
affect the freezing point. This solution is concentrated 
in the tubules, by the absorption of a part of the 
water, and by an exchange between this solution 
and the blood serum of a certain number of NaCl 
molecules for an equal number of organic molecules. 
A determination of the relative number of molecules 
of NaCl, and of organic molecules, will enable us to 
measure the part played by the parenchyma or 
glomeruli, and that played by the tubular epithelial 
cells, in the formation of the urine in question. So- 
dium chloride is easily determined by titration. 
(See p. 27.) One per cent, of NaCl (10 grms. per 
liter), is known to depress the freezing point 0.605 



102 DIAGNOSIS BY THE URINE. 

C. The per cent, of NaCl multiplied by 0.605 w ^l 
give the amount of depression caused by the NaCl 
present, and the remainder of the observed depression 
will be due to the organic molecules. We can thus 
determine the relative number of molecules separated 
by the glomeruli and the tubular epithelium. The 
latter is often designated by the sign 5. 

Example. — A certain urine gave a freezing point of — 1.20 C. 
The titration of the NaCl gave 1.5 per cent. The quantity of 
urine in 24 hours was 1,200 c.c. and the body -weight was 60 
kilos. Then 

• — -^ ! = 1,800 arbitrary molecules of NaCl. 



The total number of molecules was 
120 X 1,200 



60 



= 2,400. 



The organic molecules were found by deducting 1,800 from 
2,400, leaving 600 molecules as those elaborated by the epithelial 
cells of the tubules. 

These two formulae, 

A + V 
P ' 

or the expression of the total molecular diuresis, and 

or the expression of the molecular exchange or activity 
of the tubular epithelium, are two important working 
formulae. 



RESUME. IO3 

The quotient obtained by dividing the total depres- 
sion by that due to the elaborated (organic) molecules, 
A / 5 is also of use. This quotient in normal urines 
is from 1.5 to 1.7 and not outside of these limits. 
When 

AV A 
=3,000, — = 1.5 

P 8 



and when 



AV A 
= 4,000, — =1.7 

P 5 



In nephritis this last ratio may sink to 1.1, and in 
cardiac insufficiency it may rise to 2.5. This factor 
is often of great use in showing degeneration of the 
heart muscle, even when no abnormal heart sounds 
can be heard with the stethoscope. 

Cryoscopy of the urine is sometimes of great value 
in the diagnosis of both renal and cardiac disorders, 
as well as certain disorders of metabolism. 

We may state the chief uses of cryoscopy of the 
urine as follows: 

1. To determine cardiac sufficiency, or insufficiency, 
with certainty even when the stethoscope fails. 

2. To determine which portion of the renal struc- 
ture is functionally deficient, and the degree of that 
deficiency. 

3. To prognosticate uremic accidents with exact- 
ness. 



104 DIAGNOSIS BY THE URINE. 

4. In conjunction with catheterization of the ure- 
ters, we may determine whether one or both kidneys 
are the subject of disease, and the relative functional 
power of each. 

5. By it the fact has been established that functional 
permeability of the kidneys in most forms of nephritis 
is intermittent. There are periods of entire per- 
meability followed by periods of reduced permeability, 
and consequent danger of uremia. 

6. When one kidney is to be removed, for any 
cause, a cryoscopic examination of the urine from 
other one should be made to determine its condition, 
unless this can be done by the phloridzin or methylene- 
blue method. Cryoscopy is more certain and more 
quickly done, and when combined with cryoscopy of 
the blood it becomes of great value in the diagnosis. 

PYELITIS AND CYSTITIS. 

Inflammation of the pelvis of the kidney and of the 
ureters and bladder frequently occurs. Though 
much has been written in regard to the differential 
diagnosis of these conditions, it is of no real practical 
utility, since a cystitis will, if not cured, set up in- 
flammation higher up the canal, and vice versa. 
For practical clinical purposes, therefore, I will dis- 
regard much of this, and will say that when the pelvis 
of the kidney and the ureters are alone affected it is 



RESUME. 105 

called pyelitis; when, however, the inflammation 
extends to the bladder, it is called cystitis. If the 
pelvis of the kidney is the principal seat of inflam- 
mation, it is designated as cystopyelitis; if, on the 
other hand, the bladder is the center of inflammation, 
it is called pyelocystitis. These inflammations may 
be acute or chronic, but in all we find pus. A differ- 
ential diagnosis is approximately made as follows: 

Acute and chronic inflammations of the pelvis 
of the kidney and ureters are attended with acid 
urines, albumin, and pus; acute inflammations of the 
bladder, with neutral or alkaline urine, pus, but no 
albumin. 

Inflammation of the pelvis and ureters is accom- 
panied by polyuria; inflammation of the bladder, 
never. Specific gravity in pyelitis is generally below 
normal; specific gravity in cystitis, normal or above. 
No particular frequency in making water in pyelitis; 
constant desire to pass water in cystitis. Besides 
these differential points, the microscope may be used 
for the identification of renal or else of bladder 
epithelium, as the case may be. 

Should the cystitis, as is sometimes the case, be 
very severe, we will then find not only pus, but 
albumin in the urine. To differentiate this from 
pyelitis, we must refer to the specific gravity and 
reaction : In pyelitis it is generally below normal, and 
reaction acid or just neutral; in cystitis (severe), 



106 DIAGNOSIS BY THE URINE. 

specific gravity is normal or above, and reaction 
intensely alkaline, due to presence of ammonia car- 
bonate, and occasionally to ammonium sulphid. In 
doubtful cases the urine must be drawn for exami- 
nation, by means of a rubber catheter, directly from 
the kidney, guttatim* 

Apparatus required for executing all the tests contained in this 
volume: 

i. Test-tubes, one dozen. 

2. Small funnels — \ of an ounce, 6; four ounces, 6. 

3. Glass rods, different sizes, 6. 

4. Watch-glasses, 6. 

5. One nest of beakers. 

6. One wash-bottle, twelve ounces, for water. 

7. Porcelain evaporating dishes, 6. 

8. Small conic test-glasses, 6. 

9. Water -bath. 

10. Spirit-lamp. 

11. Small piece platinum foil. 

12. One pair of pincers. 

13. Small chemic balance (only necessary, however, if gravi- 

metric estimations are to be made). 

14. One urinometer float (with temperature chart). 

15. Microscope with appurtenances. 

16. One Esbach's albuminometer. 

17. One Doremus' ureometer. 

18. One Mohr's burette, fifty c. c, graduated in tenths. 

*In all urine examinations the entire quantity for twenty-four 
hours should be known, and a portion of this taken for analysis. In 
case this provision can not be carried out, the urine passed on rising 
in the morning will give the best approximate results. One gram is 
equivalent to 15.44 grains; thirty c. c. are equivalent to one ounce. 

If specimens of urine have to be sent for examination from a dis- 
tance, first measure the quantity for the twenty-four hours; then take 
its specific gravity, and to six ounces of the mixed urine add one tea 
spoonful of Squibb's chloroform, and send the same for analysis. 
The addition of the chloroform keeps the urine from fermenting. 



i 9 

20 
21 
22 

23 
24 

25 
26 
27 
28 
29 
30 
31 



RESUME. IO7 

Two sizes cut filter-paper for funnels, as stated. 

Blue and red litmus-paper. 

One liter flask. 

One 200 c. c. flask. 

One 10 c. c. pipette. 

One measuring jar for measuring urine, to hold ninety 

c. c. and graduated in T V of a c. c. divisions. 
One-half dozen flasks; sizes, four and six ounces. 
Small quantity assorted glass tubing. 
Three or four feet india-rubber tubing. 
One pipette, to deliver five c. c. 
One-eighth gross assorted corks. 
Filter stand, test-rack stand, and ring stand. 
One Ruhemann's Uricometer with long shank pipette. 



Chemicals required for executing all the tests in this volume: 

1. Water, distilled, or very pure rain-water. 

2. Alcohol, methylated, for lamp. 

3. Old oil of turpentine. 

4. Ozonized ether. 

5. C. p. hydrochloric acid. 

6. C. p. sulphuric acid. 

7. Picric acid, solution six grains to the ounce of water. 

8. Glacial acetic acid. 

9. Ordinary acetic acid (sp. gr. 1.04 to 1.045). 
10. Potash and soda in sticks. 

n. Potash in solution (strength, one part to three parts 
H 2 0). 

12. Rochelle salts. 

13. Cupric sulphate. 

14. Ammonia molybdate. 

15. Silver nitrate solution (one part of AgN0 3 to eight of 

water) . 

16. Citric acid. 

17. Ammonia. 

18. Lead acetate solution (1:8 of water). 

19. Sodium hyposulphite. 

20. Ammonium nitrate. 

21. Solution of bromin. 

22. Ferrous sulphid. 



108 DIAGNOSIS BY THE URINE. 

23. Potassium ferrocyanid. 

24. Freshly prepared tincture of guaiacum. 

25. C. p. sodium chlorid. 

26. C. p. nitric acid. 

27. Sodium nitroprussid. 

28. Chlorid of zinc. 

29. Phosphotungstic acid. 

30. Sulphanilic acid. 

31. Sodium nitrite. 

32. Solution chlorinated soda. 
^^. Sodium sulphate. 

34. Bismuth subnitrate. 

35. Ten per cent solution of a-naphthol in pure methyl or 
ethyl alchohol. 

36. Five per cent, solution of chromic acid. 

37. Iodin: C. p. potassium. Iodid, c. p. absolute alcohol. 
Carbon bisulphid. Bichramote of potassium. 

38. Phlorizin. 

39. Methylene-blue. 

The reagents used, unless stated otherwise, are solutions in 
water (1:15). 



RESUME. 



I09 



TABLE FOR CALCULATING THE ABSOLUTE SOLIDS 

IN URINE OF SPECIFIC GRAVITIES RANGING 

FROM 1.004 TO 1.030. 



Column A. 


Column B. 


Multiply by Number of Cubic Centi- Multip 


y by Number of Fluidounces 


meters of Urine Passed in of U 


rine Passed in Twenty-four 


Twenty-four Hours. 


Hours. 


Sp. gr. 1.004 0.00932 J Sp. g 


r. 1.004 0.2796 






1.005 0.001165 


1.005 °-3495 






1.006 0.01398 " l 


1.006 0.4194 






1.007 0.01631 " ' 


1.007 0.4893 






1.008 0.01864 " ' 


1.008 0.5592 






1.009 0.02097 


1.009 0.6291 






1. 010 0.02330 


1. 010 0.6990 






1. on 0.02563 


1. on 0.7689 






1. 012 0.02796 


1. 012 0.8388 






1. 013 0.03029 " * 


1. 013 0.9087 






1. 014 0.03262 


1. 014 0.9786 






1-015 0.03495 


1.015 1.0485 






1. 016 0.03728 


1. 016 1.1184 






1. 017 0.03961 " ' 


1 1. 017 1. 1883 






1. 018 0.04194 " ' 


1. 018 1.2582 






1. 019 0.04427 


1. 019 1. 3281 






1.020 0.04660 u ' 


1.020 1.3980 






1. 021 0.04893 " ' 


1. 021 1.4679 






1.022 0.05126 " ' 


1.022 i-537 8 






1.023 0.05359 


1.023 1.6077 






1.024 °-°559 2 


1.024 1.6776 






1.025 0.05825 


1.025 1-7475 






1.026 0.06058 " ' 


* 1.026 1. 8174 






1.027 0.06291 ■' ' 


' 1.027 1-8873 






1.028 0.06524 " ' 


' 1.028 1-9572 






1.029 0.06757 


1 1.029 2.0271 


" M 1-030 0.06990 " * 


1 1-030 2.0970 



IIO DIAGNOSIS BY THE URINE. 

To determine the quantity of solids, expressed 
in grams, multiply the number of cubic centimeters 
of urine passed in twenty-four hours by the figures 
found in Column A corresponding to the specific 
gravity of the urine under examination, and the 
result of such multiplication will represent the number 
of grams excreted. If the calculation is to be made 
from the fluidounces of urine voided, multiply the 
number of fluidounces of urine passed in twenty- 
four hours by the figures in Column B corresponding 
to the specific gravity of the urine examined, and the 
result will express the solids, in grams also. 



STATEMENTS OF THE RESULTS OF A COMPLETE 
ANALYSIS OF URINE. 

Analysis, No. Date, 

Patient's Name, 

Urine Passed in Twenty-four Hours, 

Reaction, 

Specific Gravity, 

Color, Odor, 

Consistence, Transparency, 

Albumin. — Very much — Considerable — Slight — Trace — None. 

(Erase those words not expressing.) 
Sugar. — Very much — Considerable — Slight — Trace — None. 

(Erase those words not expressing.) 



RESUME. Ill 

Absolute Solids, grams. 

Urea, " 

Relative Absolute Solids, " 

Urea, " 

Chlorides. — Normal — Increased — Diminished. (Erase condi- 
tion not found.) 

Phosphates. — Normal — Increased — Diminished. (Erase condi- 
tion not found.) 

Uric Acid. — Normal — Increased — Diminished. (Erase condi- 
tion not found.) 

Detritus. — Urates — Bladder cells — Kidney cells — Urethral cells 
— Vaginal cells. (Erase those not found.) 

Coloring-matters. — Urobilin — Acetone — Indican — Peptone — 
Bile — Leucin — Ty rosin. 

Blood. — Red corpuscles — White corpuscles — Pus — Mucus. 
(Erase those not found.) 

Tube-casts. — Hyaline — Epithelial — Granular — Epithelial or Hy- 
aline with Oil drops — Mucous casts — Urate cylinders — 
Urate casts simulating tube-casts. (Erase those not found.) 

Extra sedimentary deposits in a calculus, what variety? 

Ehrlich's typhoid test. 



INDEX. 



Acetic acid test, 33 
Acetone, 53 

clinical significance of, 53 
Acidity of urine, 9 
Acute nephritis, 60, 91 
Albumin, composition of, 33 

detection of, in urine, 33, 39 
by acetic acid and fer- 
rocyanid of potas- 
sium, 33 
by nitric acid, 35, 36 
by picric acid, 34, 35, 39 
in urine, 20, 33 
volumetric determination of, 

37 

by Esbach's albu- 
minometer, 37 
Alkaline phosphates, 30 

urine, 14, 16 
Ammonia carbonate, 15, 106 
Ammonium sulphid, 106 
Amount of urine in disease, 10 
Amyloid kidney, 74, 95 
Anuria, 10 
Apparatus, 106, 108 
Atrophy of kidneys, 12, 74, 94 
Average composition of urine, 1 

quantity of urine in health, 4 

Baruria, 39, 65 
Bile in urine, 44 

Rosenbach's test for, 44 to 
detect, 44 
Biliary acids, 44 
Blood-casts, 61 

8 113 



Blood-corpuscles, 46, 47, 48, 56, 

61 
Blood in urine, 46 

detection of, 48-50 

differential diagnosis of, 46 

guaiacum test for, 49 

hemin test, 49 
Brick-dust deposit, 22 
Bright's disease, 60 

cases classified, 64 

Caffein, 92 

Calcium, 22, 57 

Capillary arterio-fibrosis, 89, 94 

Carbonate of ammonia, 15, 106 

Chlorid of sodium passed, 26 

Chlorids, 26 

to determine quantity, 27 
Chronic interstitial nephritis, 69 

parenchymatous nephritis, 69 

93 
symptoms of, 69, 93 
Chyluria, 12 

Cirrhosis of kidney, 60, 87, 94 
Color of normal urine, 8, 12 
Coloring-matters of urine: bile, 
44; blood, 46; leucin, 44; ty- 
rosin, 44 
Conditions governing excretion 

of urea, 17, 18 
Congestion of kidneys, 65, 89 
active, 89 

differential diagnosis of, 
60, 89 



passive, 



ii4 



INDEX. 



Consistence of urine, 8 
Constituents of urine in disease, 

2, io 
Cryoscopy, 97, 104 
Cupric salts, 41 
Cuprous oxid, 41 
Cystin, 57 
Cystitis, 104 
Cystopyelitis, 105 

Deviations in color of urine, 12 
in composition of urine in dis- 
ease, 17 
Diabetes, 10 

insipidus, 11 
mellitus, 11, 12, 31, 38 
phosphatic, 31 
Differential diagnosis of chronic 

Bright's disease, 60 
Digitalis, 92 
Doremus ureometer, 19 

Earthy phosphates, 30 
Ehrlich's diazo reaction in ty- 

hpoid fever, 54 
Estimation of urea, 18 
uric acid, 25 

Fehling's solution, 41, 43 

composition of, 43 
Ferrocyanid of potassium, 43 

test, ss 
Fixed alkali, 15 
Forms of uric-acid crystals, 23 

Glucose, 39 
Glycosuria, 38 
Gout diathesis, 22 
Graduated burette, 28, 42 
Granular casts, 61 
Guaiacum test, 49 

Heller's test, 40 
Hematinuria, 46 
Hematuria, 46 



Hemin test, 49 
Hemorrhage, bladder, 46 

kidney, 46 
Hydrate solution, 20 
Hydruria, 10 
Hyperemia, 60, 61, 89 

active, 60, 90 

means of diagnosing, 61 

passive, 60, 90 
Hypobromite of soda, action of, 18 
Hyposulphite of sodium, 14 

Indican, 52 

Inflammation of bladder, 104 

of kidneys, 60, 61 

of pelvis, 105 

of ureters, 104 
Interstitial nephritis, 94 
Irritation of kidneys, 38, 60, 89 

Kidney degeneration, forms of, 

61, 80, 89 
Kidneys, 2 

atrophy of, 12, 74, 94 

capsule of, 3 

evidence of disease in, 18 
Kreatinin, 19 

Leucin, 45 

test for, 45 
Litmus-paper, blue, 15 

red, 15 
Liver, evidence of disease in, 18, 

38 

Mering's phloridizin method, 96 

Methods: 

Cryoscopic 97, 104 
Mering's phloridzin, 96 
Methylene-blue, 96 
Ruhemann's iodine, 25 

Methylene-blue method, 96 
Molisch's test, 41 
Molybdate of ammonia, 31, 58 
nitric acid solution of, 31 



INDEX. 



"5 



Mucous casts, 63 
Murexid test, 24, 57 

Nephritis, 22, 27, 60, 91 

acute, 60, 91 

catarrhal, 92 
diffuse, 93 

chronic, 60, 91 

parenchymatous, 92 
Neurasthenia, 84 
Nitrate of ammonia, 31 

of silver, 27 
Nitric acid test, 35, 36 
Nitrogen in urine, 21 
Normal urine, 8 
Nylander's test, 40 



Odor of urine, 
Oliguria, 10 



9> 13 



Parenchymatous nephritis, 69, 92 

chronic 
Peptone, 53 
Phosphates, alkaline, 30 

earthy, 30 
Phosphatic diabetes, 12, 31 
Phosphaturia, 12, 31 
Phosphoric acid, amount passed, 

30 
gravimetric determination of, 

3i 

to determine quantity of, 30 
Picric acid test, 35, 39 
Platinum foil, 56 
Pneumonia, 27 
Polyuria 10, 47, 105 
Potassium, 22 
Pus in urine, 51 

test for, 51 
Pyelitis, 104 
Pyelocystitis, 105 

Quantity of urea excreted, 17, 21 
of urine in summer, 5 
in winter, 4 



Reaction of urine, 9, 14 
Renal stasis, 91 

Ruhemann's iodine method, 25 
Rules for life insurance exam- 
iners, 85 

Sodium, 22 

hyposulphite of, 14 
Solids excreted in urine, 6, 64 
Spartein, 92 

Specific gravity of urine, 5, 10 
Statements of the results of a 
complete analysis of urine, no 
Suboxide of copper, 41 
Sugar, 38 

gravimetric determination of 

4i 

Heller's test, 40 
Molisch's test, 41 
Nylander's test, 40 
picric acid test, 35, 39 
presence of, in urine, 38 
test for, in urine, 39, 41 

Table for calculating absolute 

solids in urine, 109 
Temperature of urine, 7 
Tests : 

Acetic acid, 33 

Ferrocyanid of potassium, ^ 

Guaiacum, 49 

Heller's, 40 

Hemin, 49 

Molisch's, 41 

Murexia, 24, 57 

Nitric acid, 35, 36 

Nylander's, 40 

Picric acid, 35, 39 

Rosenbach's, 44 
Transparency of urine, 9, 13 
Tube-casts, 56, 61, 78 
Turpentine, 49 
Tyrosin, 45 

test for, 45 



n6 



INDEX. 



Urates, 19 
Urea, 17, 64 

conditions governing excre- 
tion of, 17, 18 
estimation of, 18 
quantity of, excreted, 17, 21 
Ureometer, 19 
Uric acid, 14, 19, 22 
estimation of, 25 

Ruhemann's estimation 
of, 25 
to detect, 24 
Urina potus, 10 
Urinary calculi, 56 

murexid test of, 57 
to test, 57 

organs, disease in, 9, 10 
sediments, 56 

organized and unorgan- 
ized, 56 
Urine, what it is, 1 
alkaline, 14, 16 
average composition of, 1 
quantity in winter in health, 

5 
chlorids, in pathologic, 27 
consistence of, 8 



Urine, constituents in disease, 2, 
10 
deviations in color of, 12 
in composition of, in 
disease, 17 
in disease, 10 

amount of, 10 
normal, 8 

acidity of, 9 
color of, 8, 12 
odor of, 9, 13 
reaction of, 9, 14 
transparency of, 9, 13 
solids excreted in, 6, 64 
specific gravity of, 5, 10 
temperature of, 7 
total solids in, 11 
Urobilin, 52 

clinical significance of, 52 
Uroerthyrin, 12, 22, 23 

to determine presence of, 23 

Venous stasis, 91 
Volatile alkali (carbonate of am- 
monia), 15 

Xanthin, 57 



}UL 11 1908 



